182 Sieper and Braun 28. Garrett S, Jenkinson TR, Kennedy LG, Whitelock HC, Gaisford P, Calin A. A new approach to defining disease status in ankylosing spondylitis. The Bath AS disease activity index. J Rheumatol 1994; 21:2286–2291. 29. Brandt J, Haibel H, Reddig J, Sieper J, Braun J. Treatment of patients with severe ankylosing spondylitis with infliximab—a one year follow up. Arthritis Rheum 2001; 44(12):2936–2937. 30. Braun J, Brandt J, Listing J, Zink A, Alten R, Golder W, Gromnica-Ihle E, Kellner H, Krause A, Schneider M, So¨ rensen H, Zeidler H, Thriene W, Sieper J. Treatment of active ankylosing spondylitis with infliximab—a double-blind placebo controlled multicenter trial. Lancet 2002; 359:1187–1193. 31. Van den Bosch F, Kruithof E, Baeten D, De Keyser F, Mielants H, Veys EM. Effects of a loading dose regimen of three infusions of chimeric monoclonal antibody to tumour necrosis factor alpha (infliximab) in spondyloarthropathy: an open pilot study. Ann Rheum Dis 2000; 59:428–433. 32. Kruithof E, Van den Bosch F, Baeten D, Herssens A, De Keyser F, Mielants H, Veys EM. Repeated infusions of infliximab, a chimeric anti-TNFalpha monoclonal antibody, in patients with active spondyloarthropathy: one year follow up. Ann Rheum Dis 2002; 61:207–212. 33. Stone M, Salonen D, Lax M, Payne U, Lapp V, Inman R. Clinical and imaging corre- lates of response to treatment with infliximab in patients with ankylosing spondylitis. J Rheumatol 2001; 28(7):1605–1614. 34. Maksymowych WP, Jhangri GS, Lambert RG, Mallon C, Buenviaje H, Pedrycz E, Luongo R, Russell AS. Infliximab in ankylosing spondylitis: a prospective observational inception cohort analysis of efficacy and safety. J Rheumatol 2002; 29:959–965. 35. Breban M, Vignon E, Claudepierre P, Devauchelle V, Wendling D, Lespessailles E, Euller-Ziegler L, Sibilia J, Perdriger A, Mezieres M, Alexandre C, Dougados M. Efficacy of infliximab in refractory ankylosing spondylitis: results of a six-month open-label study. Rheumatology (Oxford) 2002; 41(11):1280–1285. 36. Collantes-Estevez E, Munoz-Villanueva MC, Canete-Crespillo JD, Sanmarti-Sala R, Gratacos-Masmitja J, Zarco-Montejo P, Torre-Alonso JC, Gonzalez-Fernandez C. Infliximab in refractory spondyloarthropathies: a multicentre 38 week open study. Ann Rheum Dis 2003; 62(12):1239–1240. 37. Braun J, Brandt J, Listing J, Zink A, Alten R, Burmester G, Golder W, Gromnica-Ihle E, Kellner H, Schneider M, Sorensen H, Zeidler H, Reddig J, Sieper J. Long-term efficacy and safety of infliximab in the treatment of ankylosing spondylitis: an open, observa- tional, extension study of a three-month, randomized, placebo-controlled trial. Arthritis Rheum 2003; 48(8):2224–2233. 38. Temekonidis TI, Alamanos Y, Nikas SN, Bougias DV, Georgiadis AN, Voulgari PV, Drosos AA. Infliximab therapy in patients with ankylosing spondylitis: an open label 12 month study. Ann Rheum Dis 2003; 62(12):1218–1220. 39. Allali F, Roux C, Kolta S, Claudepierre P, Lespessailles E, Dougados M, Breban M. Infliximab in the treatment of spondylarthropathy, bone mineral density effect. Arthritis Rheum 2001; 44(9):S89. 40. Van den Bosch F, Kruithof E, Baeten D, Herseens A, De Keyser F, Mielants H, Veys EM. Randomized double-blind comparison of chimeric monoclonal antibody to tumour necrosis factor alpha (infliximab) versus placebo in active spondyloarthropathy. Arthritis Rheum 2002; 46:755–765. 41. van der Heijde D, Dijkmans B, Geusens P, Sieper J, De Woody K, Williamson P, Braun J. Efficacy and safety of infliximab in patients with ankylosing spondylitis: results of a randomized placebo-controlled trial (ASSERT). Arthritis Rheum 2005; 52(2):582–591. 42. D’Agostino MA, Breban M, Said-Nahal R, Dougados M. Refractory inflammatory heel pain in spondyloarthropathy: a significant response to infliximab documented by ultra- sound. Arthritis Rheum 2002; 46:840–841.
Biologic Therapies in Spondyloarthritides 183 43. Braun J, Baraliakos X, Golder W, Brandt J, Rudwaleit M, Listing J, Bollow M, Sieper J, Van Der Heijde D. Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis, before and after successful therapy with infliximab: evaluation of a new scoring system. Arthritis Rheum 2003; 48(4):1126–1136. 44. Brandt J, Listing J, Alten R, Burmester G, Gromnica-Ihle E, Kellner H, Schneider M, Soerensen H, Zeidler H, Rudwaleit M, Sieper J, Braun J. Two-year follow-up results of a controlled trial of the anti-TNF alpha antibody infliximab in active ankylosing spon- dylitis. Arthritis Rheum 2003; 48:S172. 45. Brandt J, Haibel H, Reddig J, Sieper J, Braun J. Successful treatment of severe undiffer- entiated spondyloarthropathy with the anti-tumor necrosis factor a monoclonal antibody infliximab. J Rheumatol 2002; 29:118–122. 46. Marzo-Ortega H, McGonagle D, O’Connor P, Emery P. Efficacy of etanercept in the treatment of the entheseal pathology in resistant spondylarthropathy: a clinical and magnetic resonance imaging study. Arthritis Rheum 2001; 44(9):2112–2117. 47. Gorman JD, Sack KE, Davis JC. Treatment of ankylosing spondylitis by inhibition of tumor necrosis factor alpha. N Engl J Med 2002; 346(18):1349–1356. 48. Brandt J, Khariouzov A, Listing J, Haibel H, Sorensen H, Grassnickel L, Rudwaleit M, Sieper J. Six-month results of a double-blind, placebo-controlled trial of etanercept treatment in patients with active ankylosing spondylitis. Arthritis Rheum 2003; 48(6):1667–1675. 49. Davis JC Jr, Van Der Heijde D, Braun J, Dougados M, Cush J, Clegg DO, Kivitz A, Fleischmann R, Inman R, Tsuji W. Enbrel ankylosing spondylitis study group. Recom- binant human tumor necrosis factor receptor (etanercept) for treating ankylosing spon- dylitis: a randomized, controlled trial. Arthritis Rheum 2003; 48(11):3230–3236. 50. Anderson JJ, Baron G, van der Heijde D, Felson DT, Dougados M. Ankylosing spon- dylitis assessment group criteria preliminary definition of short-term improvement in ankylosing spondylitis. Arthritis Rheum 2001; 44:1876–1886. 51. Marzo-Ortega H, McGonagle D, Haugeberg G, Green MJ, Stewart SP, Emery P. Bone mineral density improvement in spondyloarthropathy after treatment with etanercept. Ann Rheum Dis 2003; 62(10):1020–1021. 52. Dougados M, van der Linden S, Juhlin R, et al. The European spondylarthropathy study group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 1991; 34(10):1218–1227. 53. Rudwaleit M, van der Heijde D, Khan MA, Braun J, Sieper J. How to diagnose axial spondyloarthritis early? Ann Rheum Dis 2004; 63:535–543. 54. Brandt J, Kariouzov A, Listing J, Haibel H, Soerensen H, Grassnickel L, Rudwaleit M, Sieper J, Braun J. Successful treatment of patients with severe undifferentiated spondy- loarthritis with the anti-tumor necrosis factor a receptor fusion protein etanercept. J Rheumatol 2004; 31:531–538. 55. Dougados M, vam der Linden S, Leirisalo-Repo M, et al. Sulfasalazine in the treatment of spondylarthropathy. A randomized, multicenter, double-blind, placebo-controlled study. Arthritis Rheum 1995; 38(5):618–627. 56. Benitez-Del-Castillo JM, Garcia-Sanchez J, Iradier T, Banares A. Sulfasalazine in the prevention of anterior uveitis associated with ankylosing spondylitis. Eye 2000; 14: 340–343. 57. Smith JR, Levinson RD, Holland GN, Jabs DA, Robinson MR, Whitcup SM, Rosenbaum JT. Differential efficacy of tumor necrosis factor inhibition in the management of inflamma- tory eye disease and associated rheumatic disease. Arthritis Rheum 2001; 45(3):252–257. 58. Reiff A, Takei S, Sadeghi S, Stout A, Shaham B, Bernstein B, Gallagher K, Stout T. Etanercept therapy in children with treatment-resistant uveitis. Arthritis Rheum 2001; 44(6):1411–1415. 59. El-Shabrawi Y, Hermann J. Anti-tumor necrosis factor-alpha therapy with infliximab as an alternative to corticosteroids in the treatment of human leukocyte antigen B27-associated acute anterior uveitis. Ophthalmology 2002; 109(12):2342–2346.
184 Sieper and Braun 60. Kruithof E, Kestelyn P, Elewaut C, Elewaut D, Van Den Bosch F, Mielants H, Veys EM, De Keyser F. Successful use of infliximab in a patient with treatment resistant spondy- loarthropathy related uveitis. Ann Rheum Dis 2002; 61(5):470. 61. Fries W, Giofre MR, Catanoso M, Lo GR. Treatment of acute uveitis associated with Crohn’s disease and sacroileitis with infliximab. Am J Gastroenterol 2002; 97(2):499–500. 62. Munoz-Fernandez S, Hidalgo V, Fernandez-Melon J, Schlincker A, Martin-Mola E. Effect of infliximab on threatening panuveitis in Behcet’s disease. Lancet 2001; 358:1644. 63. Gomez-Reino JJ, Carmona L, Valverde VR, Mola EM, Montero MD. BIOBADASER Group. Treatment of rheumatoid arthritis with tumor necrosis factor inhibitors may predispose to significant increase in tuberculosis risk: a multicenter active-surveillance report. Arthritis Rheum 2003; 48(8):2122–2127. 64. Keane J, Gershon S, Wise RP, Mirabile-Levens E, Kasznica J, Schwieterman WD, Siegel JN, Braun MM. Tuberculosis associated with infliximab, a tumor necrosis factor alpha-neutralizing agent. N Engl J Med 2001; 345(15):1098–1104. 65. Baeten D, Kruithof E, Van den Bosch F, Van den Bossche N, Herssens A, Mielants H, De Keyser F, Veys EM. Systematic safety follow up in a cohort of 107 patients with spondyloarthropathy treated with infliximab: a new perspective on the role of host defence in the pathogenesis of the disease? Ann Rheum Dis 2003; 62(9):829–834. 66. Brown SL, Greene MH, Gershon SK, Edwards ET, Braun MM. Tumor necrosis factor antagonist therapy and lymphoma development: twenty-six cases reported to the food and drug administration. Arthritis Rheum 2002; 46(12):3151–3158. 67. Mohan N, Edwards ET, Cupps TR, Oliverio PJ, Sandberg G, Crayton H, Richert JR, Siegel JN. Demyelination occurring during anti-tumor necrosis factor alpha therapy for inflammatory arthritides. Arthritis Rheum 2001; 44(12):2862–2869. 68. Anker SD, Coats AJ. How to recover from renaissance? The significance of the results of recover, renaissance, renewal and attach. Int J Cardiol 2002; 86(2–3):123–130. 69. Chung ES, Packer M, Lo KH, Fasanmade AA, Willerson JT. Anti-TNF therapy against congestive heart failure investigators. Randomized, double-blind, placebo-controlled, pilot trial of infliximab, a chimeric monoclonal antibody to tumor necrosis factor-alpha, in patients with moderate-to-severe heart failure: results of the anti-TNF therapy against congestive heart failure (ATTACH) trial. Circulation 2003; 107(25):3133–3140. 70. Wolfe F, Michaud K. Congestive heart failure in rheumatoid arthritis: rates, predictors and the effect of anti-TNF therapy. Arthritis Rheum 2003; 48:S699. 71. Charles PJ, Smeenk RJ, De Jong J, Feldmann M, Maini RN. Assessment of antibodies to double-stranded DNA induced in rheumatoid arthritis patients following treatment with infliximab, a monoclonal antibody to tumor necrosis factor alpha: findings in open-label and randomized placebo-controlled trials. Arthritis Rheum 2000; 43(11):2383–2390. 72. De Rycke L, Kruithof E, Van Damme N, Hoffman IE, Van den Bossche N, Van den Bosch F, Veys EM, De Keyser F. Antinuclear antibodies following infliximab treatment in patients with rheumatoid arthritis or spondylarthropathy. Arthritis Rheum 2003; 48(4): 1015–1023. 73. Brandt J, Khariouzov A, Listing J, Haibel H, Soerensen H, Rudwaleit M, Schwebig A, Sieper J, Braun J. One year follow-up results of a controlled trial of a German double- blind placebo-controlled trial of etanercept in active ankylosing spondylitis. Arthritis Rheum 2003; 48:S173. 74. Cheifetz A, Smedley M, Martin S, Reiter M, Leone G, Mayer L, Plevy S. The incidence and management of infusion reactions to infliximab: a large center experience. Am J Gastroenterol 2003; 98(6):1315–1324. 75. Olivieri I, Padula A, Ciancio G, Salvarani C, Niccoli L, Cantini F. Successful treatment of SAPHO syndrome with infliximab: report of two cases. Ann Rheum Dis 2002; 61(4): 375–376. 76. Wagner AD, Andresen J, Jendro MC, Hulsemann JL, Zeidler H. Sustained response to tumor necrosis factor alpha-blocking agents in two patients with SAPHO syndrome. Arthritis Rheum 2002; 46(7):1965–1968.
Biologic Therapies in Spondyloarthritides 185 77. Mease PJ, Goffe BS, Metz J, VanderStoep A, Finck B, Burge DJ. Etanercept in the treat- ment of psoriatic arthritis and psoriasis: a randomised trial. Lancet 2000; 356:385–390. 78. Antoni C, Dechant C, Hanns-Martin Lorenz PD, Wendler J, Ogilvie A, Lueftl M, Kalden-Nemeth D, Kalden JR, Manger B. Open-label study of infliximab treatment for psoriatic arthritis: clinical and magnetic resonance imaging measurements of reduc- tion of inflammation. Arthritis Rheum 2002; 47(5):506–512. 79. Baeten D, Van Damme N, Van den Bosch F, Kruithof E, De Vos M, Mielants H, Veys EM, De Keyser F. Impaired Th1 cytokine production in spondyloarthropathy is restored by anti-TNFalpha. Ann Rheum Dis 2001; 60(8):750–755. 80. Zou J, Rudwaleit M, Brandt J, Thiel A, Braun J, Sieper J. Down-regulation of the non- specific and antigen-specific T cell cytokine response in ankylosing spondylitis during treatment with infliximab. Arthritis Rheum 2003; 48(3):780–790. 81. Zou J, Rudwaleit M, Brandt J, Thiel A, Braun J, Sieper J. Upregulation of the production of tumour necrosis factor alpha and interferon gamma by T cells in ankylosing spondylitis during treatment with etanercept. Ann Rheum Dis 2003; 62(6):561–564. 82. Wagner CL, Schantz A, Barnathan E, Olson A, Mascelli MA, Ford J, Damaraju L, Schaible T, Maini RN, Tcheng JE. Consequences of immunogenicity to the therapeutic monoclonal antibodies ReoPro and Remicade. Dev Biol (Basel) 2003; 112:37–53. 83. Baert F, Noman M, Vermeire S, van Assche G, D’ Haens G, Carbonez A, Rutgeerts P. Influence of immunogenicity on the long-term efficacy of infliximab in Crohn’s disease. N Engl J Med 2003; 348:601–608. 84. Schwab M, Klotz U. Pharmacokinetic considerations in the treatment of inflammatory bowel disease. Clin Pharmacokinet 2001; 40(10):723–751. 85. St Clair EW, Wagner CL, Fasanmade AA, Wang B, Schaible T, Kavanaugh A, Keystone EC. The relationship of serum infliximab concentrations to clinical improvement in rheuma- toid arthritis: results from ATTRACT, a multicenter, randomized, double-blind, placebo- controlled trial. Arthritis Rheum 2002; 46(6):1451–1459. 86. Rudwaleit M, Listing J, Brandt J, Braun J, Sieper J. Prediction of a major clinical response (BASDAI 50) to TNF-a blockers in ankylosing spondylitis. Ann Rheum Dis 2004; 63:665–670. 87. Rudwaleit M, Brandt J, Braun J, Sieper J. Is there a role for MRI in predicting the clini- cal response to TNF alpha blockers in ankylosing spondylitis? Ann Rheum Dis 2003; 62(suppl 1):97. 88. Braun J, Pham T, Sieper J, Davis J, van der Linden S, Dougados M, van der Heijde D on behalf of the ASAS Working Group. International ASAS consensus statement for the use of anti-tumour necrosis factor agents in patients with ankylosing spondylitis. Ann Rheum Dis 2003; 62(9):817–824. 89. van der Heijde D, Bellamy N, Calin A, Dougados M, Khan MA, van der Linden S. Preliminary core sets for endpoints in ankylosing spondylitis. Assessments in ankylosing spondylitis working group. J Rheumatol 1997; 24:2225–2229. 90. Listing J, Brandt J, Rudwaleit M, Zink A, Sieper J, Braun J. Impact of anti-TNFa the- rapy on hospitalization and days on sick leave in patients with ankylosing spondylitis. Ann Rheum Dis 2004; 63:1670–1672. 91. Tan AL, Marzo-Ortega H, O’ Connor, Fraser A, Emery P, McGonagle DG. Efficacy of anakinra in active ankylosing spondylitis: a clinical and magnetic resonance imaging study. Ann Rheum Dis 2004; 63(9):1041–1045. 92. Haibel H, Rudwaleit M, Braun J, Listing J, Sieper. Results of an open label study with Anakinra in active ankylosing spondylitis [abstr]. Ann Rheum Dis 2005; 64(2):296–298.
13 Physiotherapy Interventions for Ankylosing Spondylitis Astrid van Tubergen Division of Rheumatology, Department of Medicine, University Maastricht, Maastricht, The Netherlands INTRODUCTION Ankylosing spondylitis (AS) is associated with significant disability and increased socioeconomic costs (1). Until recently, available conventional therapies for AS were palliative at best, and often failed to control symptoms at the long run. With the introduction of the so-called ‘‘biologicals’’ that specifically inhibit mediators of inflammation, more promising effects in the long term may be expected. Physiothera- peutic interventions have always been considered as a necessary adjunct to drug therapy. But what is exactly meant by the word physiotherapy and how is it applied in AS? Traditionally, the mainstays of physiotherapy in the management of mus- culoskeletal conditions have been massage, manual therapy (manipulation and joint mobilization), electrotherapy (ultrasound, short-wave diathermy, or low-energy laser), and therapeutic exercises. In AS, various forms of physical therapy can be distin- guished: supervised individualized physical therapy, unsupervised self-administered individualized physical therapy or exercises at home, and supervised group physical therapy. For each of these forms, physiotherapeutic interventions as described above may be applied, but also hydrotherapy (pool sessions) and patient education and information may be offered (Table 1). Special forms of physical therapy for AS are inpatient physiotherapy for two to four weeks at a specialized clinic consisting of daily physical exercises and pool sessions, but also education, and spa therapy consisting of a two to four week course of balneotherapy (bathing in mineral water), hydrotherapy [immersion of (parts of) the body in water], massages, physical exercises, mud applications, and education. Patients recently diagnosed with AS may first receive a course of supervised individualized therapy. Afterwards, the patients are expected to exercise daily with- out supervision. They are often advised to join weekly group physical therapy sessions in order to enhance the effects of individual exercises. In addition, many patients attend annual courses of inpatient physiotherapy or spa therapy in combi- nation with exercises. 187
188 van Tubergen Table 1 Spectrum of Physiotherapeutic Interventions for AS Supervised exercises Individualized Group physical therapy Unsupervised individualized exercises AS-specific exercises Recreational exercises Manual therapy Massage Hydrotherapy Electrotherapy Warm and cold applications Patient information and education Inpatient physiotherapy Spa therapy Abbreviation: AS, ankylosing spondylitis. AIMS OF PHYSICAL THERAPY IN AS Pain and inflammation of muscles, joints, and connective tissue may lead to loss of muscle strength, range of motion, bone density, and endurance. The aims of physical therapy in AS in general are to: (i) maintain and improve mobility of the spine and peripheral joints, (ii) strengthen the muscles of the trunk, the legs, the back, and the abdomen, (iii) stretch the back, (iv) improve endurance, and (v) relax the body. These aims can be achieved by exercises, sporting activities, and hydrother- apy (2,3). Exercises may increase strength, mobility, and coordination, and thus improve joint stability. In hydrotherapy, the buoyancy of the water (law of Archimedes) reduces the relative weight of the body, and thus gravity on painful rheumatic joints (4,5). Warm water also provides muscle relaxation. The patient will experience a reduction in pain, which facilitates manipulating, mobilizing, and strengthening of affected joints and muscles, but also positively influences the patient’s compliance (5,6). Although the aims of physiotherapeutic interventions may differ for individual persons, some general advices may be given. Exercises to improve mobility, strength, and endurance should always be at the basis of every exercise scheme. It is recom- mended to gradually increase the intensity and frequency of the exercises. Repeating the exercises, preferably up to the maximum level, is a requisite. If joint swelling or pain occurs, the intensity or frequency should be reduced. It is possible to perform exercises in several positions, such as standing erect, kneeling, sitting, and lying on the side, on the back, or prone. Variations in posture and type of exercises are important to main- tain compliance. With the use of several materials the effects may also be enhanced. Detailed information on various forms of these physical exercises has been described in the literature, although no uniform protocol is yet available (3,6–10). Before starting an exercise program, it is important to realise that patient edu- cation plays a central role in successful management of AS. As soon as the diagnosis of AS is made, patients must be given clear explanations about the possible progres- sion of their symptoms and other potential clinical features, as well as information about prognosis and treatment. Informing the patient about the possible occurrence of spinal ankylosis will enhance compliance with proposed treatments, especially
Physiotherapy Interventions for AS 189 physiotherapy. Besides, it is of great importance that the inflammation is reasonably controlled, for instance with NSAIDs, to maximize the effects of the treatment. EXERCISE REGIMENS Several exercise regimens for AS can be distinguished. In supervised individualized exercises, performed at a physiotherapy center or—to a lesser extent—at home, education plays a central role. The therapist teaches the patient how to move, how to rest in a particular position, and which sports are appropriate (badminton, volleyball, swimming, cross-country skiing) and which are not (horse riding, cycling, football). The aim of these exercises is to teach the patient an individual exercise pro- gram which he/she can subsequently continue daily unsupervised at home. The unsupervised self-administered individualized exercises may consist of exercises learned in the supervised program, but may also include recreational exer- cises. These exercises should become a part of the patient’s daily routine. In practice, many patients find it difficult to perform daily exercises individu- ally. Supervised group physical therapy is offered mainly to stimulate and motivate the patients to continue exercising, and to provide social contacts with fellow sufferers. Also, the supervising physiotherapist closely monitors the intensity of the exercises in order to achieve improvement. Group physical therapy usually consists of one hour of physical exercises, one hour of sports, and one hour of hydrotherapy. Inpatient physiotherapy, consisting of two to four weeks daily exercising at a spe- cialized clinic, is often offered to recently diagnosed patients or to patients experiencing a flare of their disease. Treatment usually consists of exercises and pool sessions, but also other treatment modalities (e.g., ice or heat applications, massages) may be applied. Also, education about the disease and the role of patient societies is provided. A treatment at a spa center can be followed annually for two to four weeks. Beside balneotherapy, exercises (physical exercises and/or hydrotherapy) and relaxa- tion, also massages, mud packs, and education may be offered. Patients may follow a course of spa treatment in a group or on an individual basis. Spa therapy is mostly supervised and takes place (at least partly) in-house. ASSESSMENT OF EFFECTIVENESS OF PHYSIOTHERAPEUTIC INTERVENTION IN AS As described, physical therapy for AS comprises a whole spectrum of therapeutic inter- ventions. These interventions are usually not standardized and applied by nonstandar- dized physiotherapists to different patients whose disease (AS) might differ in important aspects such as activity, severity or stage of the condition to be treated. Patients may have varying degrees of involvement of the axial skeleton ranging from radiographic changes limited to the sacroiliac joints to complete fusion of the spine. Also, features such as peripheral arthritis, enthesitis, anterior uveitis, or organ involve- ment may or may not be present. All these stages may be associated with different degrees of functional limitations or disability and may require different physiothera- peutic approaches. Thereby, one should have realistic expectations if one prescribes physiotherapy to patients with AS, not only with respect to the sorts of effects of the different interventions, but also to the horizon of these effects. In fact, we are dealing
190 van Tubergen with a whole array of possible interventions (Table 1) and many possible outcomes (or prevention of certain outcomes) over considerable periods of time. In order to promote standardization in this field and allow comparison among studies, the inter- national Ankylosing Spondylitis Assessment working group (ASAS) has selected ‘‘core sets’’ of outcome measures to be used in different kinds of trials in AS. The core set for the assessment of effectiveness of physical therapy consists of: physical function, pain, stiffness, patient global assessment, and spinal mobility (Schober test, occiput-to- wall distance, and chest expansion) (11). Studies assessing the effectiveness of several forms of physical therapy in AS are now being judged on these outcome measures. EVIDENCE FOR BENEFITS OF PHYSICAL THERAPY A Cochrane review on physiotherapeutic interventions for AS summarized the avail- able scientific evidence on effectiveness of physiotherapy interventions in AS (12). Randomized and quasi-randomized studies were included if at least one of the comparison groups received some kind of physiotherapy. Altogether 43 studies were considered for inclusion in this review. Thirty-seven studies were excluded due to inappropriate study design, being a follow-up study or absence of full reports. Six randomized controlled trials (RCTs) met the inclusion criteria (2,6,13–16). The reviewers concluded that a home exercise program is better than no program, super- vised group physical therapy is better than home exercises, and that combined in-patient spa-exercise therapy followed by supervised weekly group physical therapy is better than group physical therapy alone. The results of the best evidence studies will be discussed in more detail below and are shown in Table 2. Supervised Individualized Exercises One RCT, with an additional follow-up period, assessed the effects of supervised individualized physical exercises (13,17). Patients were randomly allocated to either physiotherapy and disease education at home (n ¼ 26) or to no treatment (n ¼ 27). After four months, the patients from the control group were also offered physiother- apy sessions at home. In comparison with the control group, the intervention group Table 2 Effects of Several Forms of Physical Therapy in AS Judged According to the ASAS Core Set of Outcome Measures Treatment modality Patient Function Pain Stiffness Spinal mobility (reference number) global Supervised individual n.a. þ00 0 exercises (13,17) 0 0 0 n.a. n.a. Unsupervised individual exercises (15) þ þ00 þ Group physical therapy n.a. n.a. þ þ 0 (2,16,18) þ þþ 0 n.a. Inpatient physiotherapy (6) Spa therapy (14) Note: þ, Improvement; 0, no change in intervention group compared with a control group; n.a., not assessed. Abbreviations: AS, ankylosing spondylitis; ASAS, ankylosing spondylitis assesment working group.
Physiotherapy Interventions for AS 191 showed at four months (end of trial period) statistically significantly more improve- ment in finger-to-floor distance (mean between-group improvement ¼ 42%) and function (23%). At eight months (end of open follow-up period), only function had significantly changed in both study groups compared with results at four months. Interestingly, the intervention group showed significantly more improve- ment at four months in comparison with the control group at eight months. This reduced treatment effect might be explained by the fact that the intervention group had received more therapy sessions in the first four months compared with the con- trols in the second period of four months, implying that more therapy given on a regular basis will be more effective. Unsupervised Self-Administered Individualized Exercises The effects of unsupervised self-administered individualized exercises at home was assessed in one RCT (15). Patients were randomly selected from a database and ran- domized to either individual exercises and disease education at home (n = 100) or to no treatment (n = 100). After an intervention of six months, a completer analysis was performed. The home-based exercise intervention package significantly improved self-efficacy for exercise and self-reported levels of exercise, but no significant differ- ences between the two groups were found with respect to function, disease activity, and global well-being. Supervised Group Physical Therapy The efficacy of weekly supervised group physical therapy has been investigated in an RCT (2), and extended by a second RCT examining the effects of continuation of this therapy (18). In the first study, patients were randomly allocated to a group that followed weekly group physical therapy in addition to daily unsupervised exercises at home (n ¼ 68) or to a group that only exercised daily at home (n ¼ 76) (2). After nine months, statistically significantly more improvement in favor of the intervention group was found for thoracolumbar flexion and extension (mean between-group improvement ¼ 7%), physical fitness (5%), and global health (28%). In a second, con- secutive study, the intervention group was randomized again into a group continuing weekly group physical therapy for another nine months (n ¼ 30), and a group discon- tinuing this (n ¼ 34) (18). Both groups were advised to continue exercising at home. After nine months, statistically significantly more improvement was found in the continuation group compared with the discontinuation group in global health (28%). Function did not improve much in the continuation group (4%), but deterio- rated significantly in the discontinuation group (À28%). During the study period, the time spent on exercises at home appeared to be significantly higher in the continua- tion group than in the discontinuation group. An explanation for this could be peer pressure and encouragement by the supervisor of the continuation group stimulating home exercising (18). This may consequently also have had effects on the outcomes of the study. More recently, another RCT reported the effects of supervised group physical therapy in AS (16). Patients were randomly allocated to a group that followed an intensive group exercise program three days a week for six weeks (n = 27) or to a group that performed exercises individually at home (n = 24). After six weeks and three months, only change in spinal flexion was significantly greater in the interven- tion group than the control group. No significant differences in pain, stiffness, and
192 van Tubergen function between the two groups were found, although the intervention group had shown significant improvements in within-group comparisons. Inpatient Physiotherapy One RCT reported the effects of inpatient physiotherapy (6). Three groups of patients were studied: group A (n ¼ 15) followed three weeks of intensive inpatient physiother- apy, group B (n ¼ 15) followed during a six-week period twice weekly hydrotherapy sessions and performed individual exercises twice daily at home, group C (n ¼ 14) only performed individual exercises at home. All groups were advised to continue exercising at home after the treatment period. Significant differences among the three groups were found immediately after treatment (i.e., at six weeks) in pain, stiffness, and cervi- cal rotation, with most improvement found in the two intervention groups. However, at six months no significant differences were found between the groups in any of the outcome measures. Spa Therapy One RCT evaluated the effects of three weeks of spa therapy in combination with exercises as an adjunct to standard treatment with drugs and weekly group physical therapy in patients with AS (14). Two groups of 40 patients each received treatment at two different spas (in Austria and The Netherlands, respectively) for three weeks, and subsequently followed weekly group physical therapy for 37 weeks. A control group (n = 40) stayed at home and received weekly group physical therapy for 40 weeks. An aggregate score of questionnaires on function, patient global well-being, pain, and duration of morning stiffness was used to evaluate effects. Immediately after the spa treatment, both intervention groups showed significant improvements in this score compared with the control group. Benefit was maintained over the 40-week study period in patients receiving spa-exercise therapy, although at 40 weeks, the improvement in the aggregate score had lost statistical significance, as compared with controls. The maximum between-group improvements were 24% for functioning, 30% for pain, and 33% for global well-being. OPTIMUM THERAPEUTIC REGIMEN FOR INDIVIDUAL PATIENTS Who will benefit most from exercise therapy and how much would be the optimum? To assess whether patients with particular characteristics would benefit more from physical therapy than others, several studies performed additional subgroup ana- lyses. Most studies reported no influence on treatment effect by the duration of the disease (19), disease severity (6), a reduction in range of motion (6), the degree of chest expansion or restrictive lung disease (20,21). Also, improvements were equally found in men and women in one study (22), whilst others found a trend for women to improve more than men, and moreover, patients who had attended fewer courses of inpatient physiotherapy tend to achieve more improvement, and younger patients appeared to do better than older patients (23). One study reported that in patients with <15 years of AS, performing recreational exercises—but not back exercises—was associated with improvement in pain and stiff- ness, but not function (24). Among patients with more than 15 years of AS, performing back exercises—but not recreational exercises—was associated with improvement in
Physiotherapy Interventions for AS 193 pain and function. It is recommended to exercise at least 30 minutes a day, at least five days a week, and to perform back exercises rather than recreational exercises, because these were associated with better functional outcome in the long term (24). Another study assessed the effects of the intensity and frequency of exercises (including sports, AS-specific exercises, and hydrotherapy) on disease activity and function (25). Exercising at a moderate level was associated with improved function and lower disease activity, and exercising at an intensive level was associated with improved function, but not disease activity. It may be concluded that consistency rather that quantity is of most importance (25). ADVANTAGES AND DISADVANTAGES OF EXERCISE THERAPIES Each treatment modality has its advantages and disadvantages. The advantages of supervised individualized exercises are personal contact with a therapist and possi- bility to adapt an exercise program to individual needs. However, a disadvantage may be decreased motivation because of long-lasting and monotonous treatment. Unsupervised individual exercises can be performed at any time of the day and may consist of AS-specific exercises or sporting activities. Also with individual exer- cises, it may be difficult to maintain discipline, and patients may get bored of the same, repeating exercises. Team sporting activities are often not suitable for a patient with AS, because of the competitive elements that may cause injuries to an indivi- dual with AS. Advantages of group physical therapy over unsupervised exercises alone are mutual encouragement, increased motivation to carry out home exercises, exchange of experience, contact with fellow sufferers, and personal feedback (2). Patients attending group physical exercises tend to spend more time on individual exercises compared with those who do not participate in group programs (18). However, there are also several disadvantages: motivation and energy may not be optimal after working hours, and for practical, logistic reasons (group therapy is usually provided only once or twice a week) patients may decide not to participate (2). Advantages of two to four weeks of inpatient physiotherapy or spa therapy are intensive supervision, together with education, and encouragement of the patients, and the possibility to achieve improvements in a short term (6). The main disadvan- tages are high costs and difficulties patients who are employed may encounter in being absent from work. IMPLICATIONS FOR PRACTICE Physical therapy plays a central role in the overall management of patients with AS. Although the evidence for efficacy of physical therapy in AS is scanty, in general, it seems that physical therapy might be effective and would be beneficial to all kinds of patients. Patients should consider exercising as part of their daily routine. Depending on their personal needs and preferences, disease activity and severity, patients may opt for unsupervised (recreational or AS-specific) exercises alone or may also attend group physical therapy sessions. If necessary, they may follow an inpatient course of physiotherapy or engage in spa therapy. The paucity of data makes it difficult to identify the best administration mode of these interventions based upon scientific evidence today.
194 van Tubergen Self-management of the patient is a prerequisite to success, with the basis lying initially at the treating physician convinced of the need of exercising and referring the patient to a physiotherapist. Inspired and motivated by the physiotherapist to follow a time-consuming exercise program, the patient may eventually benefit from a better disease outcome (26). REFERENCES 1. Boonen A. Socioeconomic consequences of ankylosing spondylitis. Clin Exp Rheumatol 2002; 20(suppl 28):S23–S26. 2. Hidding A, van der Linden S, Boers M, et al. Is group physical therapy superior to individualized therapy in ankylosing spondylitis? A randomized controlled trial. Arthritis Care Res 1993; 6:117–125. 3. Viitanen JV, Suni J. Management principles of physiotherapy in ankylosing spondylitis— which treatments are effective? Physiotherapy 1995; 81:322–329. 4. McNeal RL. Aquatic therapy for patients with rheumatic disease. Rheum Dis Clin North Am 1990; 16:915–929. 5. Machtey I. Hydrotherapy and balneotherapy: state of the art. In: Balint G, Go¨ mo¨ r B, Hodinka L, eds. Rheumatology, State of the Art. Amsterdam: Excerpta Medica, 1992: 390–392. 6. Helliwell PS, Abbott CA, Chamberlain MA. A randomised trial of three different physiotherapy regimens in ankylosing spondylitis. Physiotherapy 1996; 82:85–90. 7. Simon L, Blotman F. Exercise therapy and hydrotherapy in the treatment of rheumatic diseases. Clin Rheum Dis 1981; 7:337–347. 8. Rasmussen JO, Hansen TM. Physical training for patients with ankylosing spondylitis. Arthritis Care Res 1989; 2:25–27. 9. Gall V. Exercise in the spondyloarthropathies. Arthritis Care Res 1994; 7:215–220. 10. Stucki G, Kroeling P. Physical therapy and rehabilitation in the management of rheu- matic disorders. Baillieres Best Pract Res Clin Rheumatol 2000; 14:751–771. 11. van der Heijde D, Calin A, Dougados M, Khan MA, van der Linden S, Bellamy N. Selection of instruments in the core set for DC-ART, SMARD, physical therapy, and clinical record keeping in ankylosing spondylitis. Progress report of the ASAS Working Group. J Rheumatol 1999; 26:951–954. 12. Dagfinrud H, Hagen K. Physiotherapy interventions for ankylosing spondylitis. Cochrane Database Syst Rev 2004; 4:Cd002822. pub 2. 13. Kraag G, Stokes B, Groh J, Helewa A, Goldsmith C. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis—a randomized controlled trial. J Rheumatol 1990; 17:228–233. 14. van Tubergen A, Landewe R, van der Heijde D, et al. Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Arthritis Rheum 2001; 45:430–438. 15. Sweeney S, Taylor G, Calin A. The effect of a home based exercise intervention package on outcome in ankylosing spondylitis: a randomized controlled trial. J Rheumatol 2002; 29:763–766. 16. Analy Y, E. O, Karan A, Diracoglu D, Aydin R. The effectiveness of intensive group exercise on patients with ankylosing spondylitis. Clin Rehabil 2003; 17:631–636. 17. Kraag G, Stokes B, Groh J, Helewa A, Goldsmith CH. The effects of comprehensive home physiotherapy and supervision on patients with ankylosing spondylitis—an 8-month follow-up. J Rheumatol 1994; 21:261–263. 18. Hidding A, van der Linden S, Gielen X, de Witte L, Dijkmans B, Moolenburgh D. Continuation of group physical therapy is necessary in ankylosing spondylitis: results of a randomized controlled trial. Arthritis Care Res 1994; 7:90–96.
Physiotherapy Interventions for AS 195 19. Hidding A, van der Linden S, de Witte L. Therapeutic effects of individual physical ther- apy in ankylosing spondylitis related to duration of disease. Clin Rheumatol 1993; 12:334–340. 20. Fisher LR, Cawley MI, Holgate ST. Relation between chest expansion, pulmonary func- tion, and exercise tolerance in patients with ankylosing spondylitis. Ann Rheum Dis 1990; 49:921–925. 21. Seckin U, Bolukbasi N, Gursel G, Eroz S, Sepici V, Ekim N. Relationship between pul- monary function and exercise tolerance in patients with ankylosing spondylitis. Clin Exp Rheumatol 2000; 18:503–506. 22. Tomlinson MJ, Barefoot J, Dixon ASJ. Intensive in-patient physiotherapy courses improve movement and posture in ankylosing spondylitis. Physiotherapy 1986; 72: 238–240. 23. Band DA, Jones SD, Kennedy LG, et al. Which patients with ankylosing spondylitis derive most benefit from an inpatient management program? J Rheumatol 1997; 24:2381–2384. 24. Uhrin Z, Kuzis S, Ward MM. Exercise and changes in health status in patients with ankylosing spondylitis. Arch Intern Med 2000; 160:2969–2975. 25. Santos H, Brophy S, Calin A. Exercise in ankylosing spondylitis: how much is optimum? J Rheumatol 1998; 25:2156–2160. 26. Calin A. Can we define the outcome of ankylosing spondylitis and the effect of physiotherapy management? J Rheumatol 1994; 21:184–185.
PART IV: SURGERY FOR SPINAL DEFORMITIES IN ANKYLOSING SPONDYLITIS 14 Anesthesiological Considerations for the Ankylosing Spondylitis Patient Jaap J. de Lange and Wouter W. A. Zuurmond Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands Ankylosing spondylitis (AS) is an inflammatory systemic disease affecting the sacroiliac joints and spine leading to ankylosis and ‘‘bamboo spine,’’ and adjacent soft tissues. Systemic involvement may result in weight loss, fatigue, low-grade fever, conjunctivitis, uveitis, pulmonary fibrosis in the upper lobes, aortic regurgitation due to thickening of the valve cusps, dilatation of the valve annulus, and cardiac conduction abnormalities. Human leucocyte antigen (HLA)-B27 may be positive in more than 90% of the patients, which may explain the high familial incidence. The inflammatory disease may affect 1.6% of the population, four times as many males as females. The severity of AS varies from mild stiffness and pain in the sacroiliac joints to severe systemic abnormalities and deformities especially of the cervical and thoracic spinal joints (1–3). Anesthesia in patients with AS poses a number of specific problems. PREOPERATIVE CONSIDERATIONS Predictability and Handling of Musculoskeletal Involvement Upper Airway What are the possible risk factors and available tests for diagnosing airway difficulty (4,5)? Ankylosing of the Cervical Spine. Cervical spine stiffness interferes with the flexion and extension of the neck. During the preoperative visit of the patient suffering from AS, evaluation of the upper airway has to be performed meticulously. Diagnosing an obvious difficulty for intubation is mostly easy and this makes the anesthesiologist aware of the prob- lems which may arise during intubation. Relative Tongue/Pharyngeal Size, the Mallampati Test (6). The size of the tongue in relation to the size of the oral cavity can be simply and visually graded by how much of the pharynx is obscured by the tongue. 197
198 de Lange and Zuurmond The purpose of the test is: classifying the view of pharyngeal structures, defining the size of the tongue in relation to the size of the oral cavity, and visually grading how much the pharynx is obscured by the tongue. The test is performed by asking the patient to maximally protrude the tongue from a fully open mouth while sitting upright. The pharyngeal structures are inspected and classified into four grades: Class I: faucial pillars, soft palatine and uvula are visible, Class II: faucial pillars and soft palatine can be visualized, but the uvula is— partially—masked by the base of the tongue, Class III: only the soft palatine and the base of the uvula can be visualized, or Class IV: soft palatine is not visible. Class III and Class IV are associated with increasing difficulty to intubate. Atlanto-occipital Joint Extension and Flexion. When the neck is slightly to moderately flexed on the chest and the atlanto-occipital joint is well extended, result- ing in an extended head on the neck, the oral, pharyngeal, and laryngeal axes are brought more nearly into a straight line, the well-known ‘‘sniffing-the-morning- air-position.’’ In this position less of the tongue will obscure the view of the larynx and, consequently, there will be much less need for strenuous effort to bring the tongue forward. In healthy people, a mean extension of 25–35 grades occurs at level C1–C2. However, to consider movement between C0–C1 and C1–C2 as separate would be inappropriate. The extension takes place at C0–C2 and amounts to 35. The patient has to be evaluated by sitting straight with head held erect and facing directly to the front. In this position the occluded surface of the upper teeth is horizontal and parallel to the ground. The patient then extends the atlanto- occipital joint as much as possible and the examiner measures the angle traversed by the occluded surface of the upper teeth. Any reduction in extension can be as a fraction of the normal. When the atlanto-occipital gap cannot be extended, the laryngoscopist will cause an increase in the convexity of the cervical spine, which will bring the larynx further forward. Patients who suffer with rheumatoid disease of the neck or degen- erative spinal diseases often have reduced neck mobility making intubation harder. The Space Anterior to the Larynx, the So-called ‘‘Mandibular Space.’’ The mandibular space can be measured by a ruler or by a number of finger breadths. The thyromental distance, the distance between the inside of the mandible to the hyoid bone has to be >6 cm or two fingers or more. The horizontal length of the mandible has to be >9 cm. These measurements are tightly associated with a low tongue/pharyngeal size classification and strongly suggest that direct laryngoscopy will be easy. When there is a large mandibular space, the tongue is easily compressed into a large compartment and does not have to be pulled maximally forward in order to reveal the larynx. Jaw Movement. Two aspects of jaw movement are significant when assessing difficult intubation: The interdental gap—mouth opening permits adequate insertion of the laryngoscope and tube. Limited movement of the mandible is a recognized cause of difficult intubation. This may be related to temporomandibular dysfunction or trismus. In AS patients the incidence of temporomandibular
Anesthesiological Considerations for the AS Patient 199 joint involvement varies between 10% and 40%. Cricoarythenoid involve- ment may be expected if dyspnea or hoarseness occurs (1). Subluxation of the jaw—the maximal forward protrusion of the lower inci- sors beyond the upper incisors. Good forward protrusion of the mandible provides additional space for forward displacement of the tongue. View Obstruction. Dentition: unusually long upper incisors, the so-called buck teeth, may adversely affect the position of the upper end of the line of sight. In addition, a receding mandible may indicate that the tongue is positioned more at the back than usually, blocking the view. Finally, a body weight more than 110 kg or a Quetelet index >30 may interfere with intubation. The above mentioned tests and limitations cannot be seen alone and a combi- nation of the above tests is better than using only one to predict difficulties in intubation. Anesthesia in patients with AS with a difficult airway may lead to the following complications: Direct trauma the airway and surrounding tissues upper airway resulting in hemorrhage, lacerations and subsequent tissue emphysema and risk of infection chipped or broken teeth fracture of the facial bones fracture-subluxation of the cervical spine Directly mediated reflexes laryngovagal (airway spasm, apnea, bradycardia, arrhythmia, or hypo- tension) laryngosympathetic (tachycardia, tachyarrhythmia, or hypertension) laryngospinal (coughing, vomiting, or bucking) Interruption of the gas exchange hypoxia and hypercapnia which may cause brain injury, myocardial infarction and death Both direct trauma and morbidity from airway obstruction may range from minor to major and life threatening. Criteria during difficult intubation are classified according to Cormack and Lehane (7). These criteria are defined for the patient in position supine with the head in the sniffing position. Grades 1 and 2 are considered to be adequate exposure and grades 3 and 4 inadequate exposure. Grade 1: Glottis including anterior and posterior commissures could be fully exposed Grade 2: Glottis could be partly exposed and anterior commissure could not be visualized Grade 3: Glottis could not be exposed, corniculate cartilages only could be visualized Grade 4: Glottis including corniculate cartilages could not be exposed. Difficult Intubation Strategies In the United States, guidelines for difficult airway management were developed by a nine-person task force appointed by the American Society of Anesthesiologists
200 de Lange and Zuurmond (ASA) Ad Hoc Committee on Practice Parameters (8). A difficult intubation drill was introduced. Three basic problems may occur alone or in combination: difficult intubation, difficult ventilation, and/or difficulty with patient cooperation or consent. Difficult intubation may or may not be accompanied with difficulty in mask ventilation. In these cases, we have to consider the relative merits and feasibility of basic management choices: use of nonsurgical techniques versus surgical technique, preservation of spontaneous ventilation during intubation versus ablation of spontaneous ventilation during intubation attempts, and awake intubation versus intubation attempts after induction of anesthesia. Concerning awake intubation preoperative preparation and information of the patient combined with local anesthetic techniques may facilitate this procedure. Awake Intubation. During awake intubation, intravenous sedation may be administered. However, respiratory depression or losing verbal contact with the patient has to be prevented. There are two important nerve blocks for decreasing discomfort of the patient during awake intubation: the bilateral blockage of the lingual branch of the IX nerve and the superior laryngeal block. First, the bilateral blockage of the lingual branch of the IX nerve eliminates the gag reflex. The tongue of the patient is gently retracted laterally, exposing the palatoglossal arch. The palatoglossal arch is pierced approxi- mately 0.5 cm from the lateral margin of the root of the tongue at the point at which it joins the floor of the mouth. The needle is inserted 0.5 cm and 2 mL of 2% lidocaine is inserted after a negative aspiration test. Secondly, the internal branch of the superior laryngeal nerve can be blocked. The superior laryngeal block consists of application of local anesthetic superficial and deep to the inferior lateral cornu of the hyoid bone. The nerve pierces the mem- brane at this point and can be blocked at either sides of the membrane. Furthermore topical spray (lidocaine 10%) may be applied. Intubation Techniques Orally with direct laryngoscopy, the conventional technique. In many countries modifications on the normal laryngoscope have been commer- cially available, for example, the Bullard (9). New types of laryngoscopes and new techniques should not be practiced for the first time during a diffi- cult intubation. All new inventions have to be evaluated thoroughly. Orally over a guiding stylet. A modification on the guiding stylet is the illuminating stylet. Nasal intubation with laryngoscope. Nasal intubation after first oral attempt. Blind nasal intubation. Laryngeal mask (10,11). Intubation with flexible bronchoscope. A flexible laryngoscope is the most useful aid to awake intubation in the patient with the difficult airway. Fiber-optic-aided intubation can be performed using the oral or nasal route. After successful passage through the vocal cords, a tube can be inserted over the fiberscope (12).
Anesthesiological Considerations for the AS Patient 201 It is recommendable to use a mask with a hole to permit passage of the fiberscope. Retrograde translaryngeal-guided intubation. Retrograde intubation techniques have been in use for several decades. Retro- grade intubation seems to be an underused elective or emergency intubation techni- que in the management of the difficult airway. After properly positioning the patient, the skin and underlying tissue have to be infiltrated with local anesthetics and punctured, two segments lower than the cricothyroid membrane at an angle of 30. The puncture pressure may be high and care must be taken to prevent piercing the opposite side of the trachea. A simple way to detect the airway can be utilized to connect the needle with the capnograph. An epidural set may be used. After insertion of the epidural needle, a catheter has to be inserted and guided to the mouth. If nasal intubation is demanded, a nasal airway may guide the epidural catheter to the entrance of the nose (13). Learning this technique could be a problem: for ethical reasons, it is not usual to perform these techniques in normal patients: coniotomy and high frequency ventilation, or tracheotomy. Conclusion. The prediction of difficult intubation preoperatively may save lives in the future. An emergency drill has to be available. Techniques for difficult intubation have to be learned. The choice of the intubation technique depends mainly on the experience of the anesthesiologist. Spinal Involvement The entire ankylosed spine in these patients needs special attention. It is mandatory to prevent excessive manipulation of the cervical spine, especially during intubation and positioning of the patient, to prevent fracture of the spine and subsequent spinal cord injury. A difficult position for the AS patient is the prone position. Meticulous attention should be paid to maintain the patient’s own posture. It is extremely important not to offend patients’ ‘‘own anatomy.’’ Positioning of the patient should be a close collaboration between anesthesiologist and surgeon. A consequence of thoracic spinal involvement may be a ‘‘stiff thorax’’ with decreased rib cage movement resulting in impaired lung function. Preoperative evaluation of lung function is essential. The abnormalities in the spine may some- times shut the door on performing regional anesthesia (epidural and/or spinal) due to limited joint mobility and closed interspinous spaces (14). An increased risk of epidural hematoma in patients with AS may be present especially in multiple attempts either to puncture or to place the catheter (15). External cardiac massage may be hindered by the ‘‘stiff thorax.’’ Predictability and Handling of Respiratory System Involvement The upper lobe pulmonary fibrosis may be diagnosed by chest X-ray. The X-ray find- ings may not be mistaken for tuberculosis (2). Postoperatively special attention should be paid to the respiratory parameters in case of impairment of the lung function.
202 de Lange and Zuurmond Predictability and Handling of the Cardiovascular System Involvement Preoperative evaluation of the cardiovascular system has to be done to exclude extension of the disease to the connective tissue of the aorta and aortic valve cusp resulting in aortic valve insufficiency and heart rhythm disturbances. Stoke Adams attacks may occur due to conduction defects (1–3): preoperative examination involves EKG to detect left ventricular hypertrophy and conduction defects and echocardiography to detect aortic valvular disease. Predictability and Handling of the Neurological System Involvement Neurological deficits are common in patients suffering from AS. Meticulous preop- erative neurological evaluation is mandatory not only for achieving adapted proper positioning during anesthesia and operation, but also for forensic reasons, especially when regional techniques are performed. Predictability and Handling of Concomittant Problems Patients suffering from AS may have impaired renal function due to amyloidosis and/or due to chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs). Preoperative full blood count, urea and electrolytes, and clotting time have to be investigated term NSAID’s prescriptions. INTRAOPERATIVE CONSIDERATIONS Anesthetic Technique The anesthetic technique for the AS patient is not different from other patients and should be tailor-made to the patient’s condition, and the extent of the operation. However, as mentioned before special attention should be paid to proper positioning of the patient, intubation possibilities and conditions, and postoperative respiratory problems and pain relief. Blood Loss Intraoperatively, the anesthesiologist has to deal with blood loss during spinal sur- gery. To prevent and/or treat excessive blood loss the following special measures could be performed: 1. Prevention and immediate treatment of clotting disorders. 2. Applying cell saver techniques. 3. Sampling and storing of autologous blood in the preoperative period. 4. Pretreatment of the patient by means of erythropoietine (16). This should be planned three to four weeks before the surgical procedure. 5. Controlled hypotension during moments of the excessive blood loss. This technique is controversial, because it depends on the patient’s condition: disturbed neuroautoregulation of the central nervous system and hypoten- sion is not a preferable combination and may lead to neurological deficits. For this reason the decision to apply controlled hypotension should be made carefully.
Anesthesiological Considerations for the AS Patient 203 Spinal Cord Monitoring The development of spinal cord monitoring techniques has replaced the old fash- ioned ‘‘wake up test’’ during spinal surgery. To detect spinal threatening due to surgery two techniques are available: 1. Monitoring somatosensory evoked potentials (SSEP), or 2. Transcranial electro-motor evoked potentials. Most experience has been achieved with SSEP. By electrical stimulation of a peripheral nerve (e.g., the post-tibial nerve) the response in the cerebral cortex is monitored. Interruption of the signal indicates threatening of spinal damage and immediate restoration of spinal cord function may be still possible. With this tech- nique one monitors the integrity of the somatic sensory system, thus the dorsal part of the medulla. Applying the second technique the integrity of the motor system of the medulla (the ventral part) is monitored. This technique is especially suitable for monitoring the function of the spinal cord during aortic surgery. Both techniques demand a standardized anesthetic technique. All inhaled anesthetic agents cause a marked dose-related depression of the signal; nitrous oxide does not influence latency time, but depresses the amplitude of the signal by 50%. Con- tinuous infusion of an opioid combined with propofol has proven to be the preferable anesthetic technique, because propofol shows more stability of the signal (17,18). Monitoring of SSEP has to be started in the awake patient to obtain reference values. During the crucial moments of surgery the anesthesia has to be performed smoothly by continuous infusion without top up doses. POSTOPERATIVE CONSIDERATIONS Respiratory Aspects Postoperative artificial ventilation is needed if the respiratory function is marginal and a smooth recovery is demanded. In AS patients, extubation should be performed if the patient has fully recovered from anesthesia, because the necessity to re-intubate could be disastrous. Pain Relief Special attention should be paid to proper postoperative pain relief: insufficient pain relief may result in hypoventilation and too high doses of opioids may result in over- sedation, respiratory depression, and insufficient coughing. Tailor-made analgesia may be achieved by personal attention and patient controlled analgesia with opioids. Administering NSAIDs is only indicated in patients without renal impairment or excessive blood loss. Epidural analgesia is preferable, but often not technically feasible. Sometimes it is possible to place an epidural catheter during the operation by the surgeon. REFERENCES 1. Campbell A, Hamilton-Davies C. Ankylosing spondylitis. In: Pollard BJ, ed. Handbook of clinical anaesthesia. 2nd. London: Churchill Livingstone, 2004:232–234.
204 de Lange and Zuurmond 2. Stoelting RK, Dierdorf SF. Anaesthesia and co-existing disease. Chapter 26. Skin and musculoskeletal diseases. 4th ed. London: Churchill Livingstone, 2002:532. 3. Allman KG, Wilson IH. Ankylosing spondylitis. Oxford Handbook of Anaesthesia. Oxford: Oxford University Press, 2001:163. 4. Benumof JL. Management of the difficult airway. With special emphasis on awake tracheal intubation. Anesthesiology 1991; 75:1087–1110. 5. Benumof JL. Airway management. Principles and practice. St Louis: Mosby-Year Book 1996. 6. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation. A prospective study. Can J Anaesth 1985; 32:429–434. 7. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39:1105–1111. 8. Practice guidelines for management of the difficult airway: a report by the American society of anesthesiologists task force on management of the difficult airway: Anesthesiology 1993; 78:597–602. 9. King TA, Adams AP. Failed tracheal intubation. Br J Anaesth 1990; 65:400–414. 10. Lu PP, Brimacombe J, Ho AC, Shyr MH, Liu HP. The intubating laryngeal mask airway in severe ankylosing spondylitis. Can J Anaesth 2001; 48(10):1015–1019. 11. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubat- ing LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology 2001; 95(5):1175–1181. 12. Ovassapian A. Fiberoptic endoscopy and the difficult airway. Philadelphia: Lippincott- Raven, 1996. 13. Bourke D, Levesque PR. Modification of retrograde guide for endotracheal intubation. Anesth Analg 1974; 53:1013–1014. 14. Schelew BL, Vaghadia H. Ankylosing spondylitis and neuraxial anaesthesia—a 10 year review. Can J Anaesth 1996; 43(1):65–68. 15. Gustafsson H, Rutberg H, Bengtsson M. Spinal haematoma following epidural analge- sia. Report of a patient with ankylosing spondylitis and a bleeding diathese. Anaesthesia 1988; 43:220–222. 16. Faris PM, Ritter MA, Abels RI. The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation. J Bone Joint Surg Am 1996; 78:62–72. 17. Kalkman CJ, Traast H, Zuurmond WWA, Bovill JG. Differential effects of propofol and nitrous oxide on posterior tibial nerve somatosensory cortical evoked potentials during alfentanil anaesthesia. Br J Anaesth 1991; 66:483–489. 18. Scheepstra GL, De Lange JJ, Booij LHDJ, Ros HH. Median nerve evoked potentials during propofol anaesthesia. Br J Anaesth 1989; 62:92–94.
15 Lumbar Osteotomy in Ankylosing Spondylitis: A Structured Review of Three Methods of Treatment Arthur de Gast Department of Orthopaedic Surgery, VU University Medical Center, Amsterdam, The Netherlands INTRODUCTION Ankylosing spondylitis (AS) mainly affects the synovial joints and soft tissue struc- tures of the axial skeleton. Inflammatory processes in the intervertebral joints even- tually lead to ankylosits, which together with ossification of the anterior and posterior longitudinal ligaments render the spine into a rigid beam. Despite maxi- mum conservative treatment, stiffening of the spine in an advert position can occur. In AS, this mostly is a combination of a thoracic hyperkyphosis and flattening of the lumbar lordosis: a thoracolumbar kyphotic deformity (TLKD) (1–5). A severe TLKD can prevent the patient from sitting, standing, or lying comfor- tably, especially if the TLKD is accompanied by a flexion contracture of the hip joints that adds up to the total flexion deformity of the patient’s body. Also, patients with a TLKD lose the ability to see straight forward to the horizon. Obviously, the physical posture and impairments caused by a TLKD also have strong psychological and social implications (Fig. 1) (67,68). A corrective spinal osteotomy may be considered in selected cases. The main goal of a corrective spinal osteotomy is to restore the patient’s spinal balance and the restoration of a horizontal view angle (Fig. 2). Positive side effects of a corrective spinal osteotomy are to relieve compression of the abdominal viscera by the margin of the inferior rib cage, and improvement of diaphragmatic respiration. The TLKD is best corrected by a lordosating osteotomy of the lumbar spine, as thoracic correction is strongly limited by ankylosis of the costovertebral joints (3,4,6–11). Furthermore, the overall correction is greatest when the intervention is performed at the lowest possible level of the lumbar spine (7,9,12,13). In addition, the relative narrow thoracic spinal canal renders the mid-thoracic spinal cord more vulnerable to perioperative injury than the cauda equina in its spacious spinal canal. 205
206 de Gast Figure 1 Clinical photograph of a patient with a severe TLKD due to AS. Note the extension of the hip joints, the kyphotic deformity of the spine, and the inability to look straight forward. Abbreviations: TLKD, thoracolumbar kyphotic deformity; AS, ankylosing spondylitis. Reports on lumbar osteotomies for correction of TLKD attributable to AS are limited. Most authors reported results of only few patients (7,14–25). Few authors, however, have experience with more than 50 patients (9,12,26–28,66). HISTORY AND CURRENT OPTIONS FOR SURGICAL TREATMENT There are a number of descriptions of operative techniques for the correction of TLKD. Still, these descriptions can be reduced to three basic operative techniques to correct TLKD resulting from AS at the level of the lumbar spine: opening wedge osteotomy, polysegmental wedge osteotomies, and closing wedge osteotomy (Figs. 3–5). Opening Wedge Osteotomy The original technique is commonly credited to Smith-Petersen et al. (10), who reported an anterior opening wedge osteotomy in six patients in 1945. This technique involves two- and three-level osteotomies removing the articular processes of L1,
Lumbar Osteotomy in Ankylosing Spondylitis 207 Figure 2 Clinical photograph of the same patient after surgical correction of the patient’s posture by means of an extending lumbar osteotomy (in this case a single-level closing wedge osteotomy). Note among others, the restoration of the patient’s view angle as compared with Figure 1. L2, and L3 (10). Correction of the kyphotic deformity was then achieved by forceful manual extension of the lumbar spine in an attempt to close the posterior wedge osteotomies. Obviously, this forceful manipulation must cause a disruption of the anterior longitudinal ligament and vertebral structures to create an anterior mono- segmental intervertebral opening wedge with elongation of the anterior column (Fig. 6). In the same period, the Dutch orthopedic surgeon La Chapelle (20) described a two-stage anterior opening wedge osteotomy for correction of TLKD in one patient. First of all he removed the lamina of L2 under local anesthesia, followed two weeks later by an anterior release and resection of the intervertebral disc between L2 and L3. The anterior osteotomy was then wedged open and grafted with a bone block. Since then, many modifications of this anterior opening wedge osteotomy have been described (1,3–6,11,12,15,26,27,29–39,67). The sharp lordotic angle and elon- gation of the anterior column resulting from this procedure were believed to be asso- ciated with serious vascular and neurological complications (6,12,19,24,26,33,36,38). To avoid such complications, polysegmental posterior wedge osteotomies and closing wedge posterior osteotomies of the lumbar spine were introduced.
208 de Gast Figure 3 Diagrams of the OWO. (A) Lateral view outlining the bone block to be resected. (B) Postoperative lateral view showing how correction is achieved by closure of the posterior elements, and creating an open wedge of the anterior column. Abbreviation: OWO, opening wedge osteotomy. Figure 4 Diagrams of the PWO. (A) Lateral view outlining the bone blocs to be resected through the original facet joints in the direction of the interspinal foramen. (B) Postoperative lateral view showing how correction is achieved by closure of the posterior osteotomies. Abbreviation: PWO, polysegmental wedge osteotomies.
Lumbar Osteotomy in Ankylosing Spondylitis 209 Figure 5 Diagrams of the CWO. (A) Lateral view outlining the bone block to be resected. (B) Postoperative lateral view showing how correction is achieved by closure of the intraver- tebral osteotomy. Abbreviation: CWO, closing wedge osteotomy. Polysegmental Wedge Osteotomy In 1949, Wilson and Turkell (25) were the first to report a patient with TLKD attrib- utable to AS treated by polysegmental lumbar posterior wedge osteotomies. Correc- tion was achieved by extending the lumbar spine after multiple lumbar posterior closing wedge osteotomies, including removal of tissues in the interlaminar space and the inferior and superior articular processes. This method provides a more gra- dual correction without rupturing of the anterior longitudinal ligament (Fig. 4). In the 1980s, Zielke (40–44) also advocated polysegmental lumbar posterior wedge osteotomies, but, in contrast to his predecessors, with the use of internal fixation. He and his colleagues first used Harrington rods and laminar hooks, and later, trans- pedicular screws (9). Closing Wedge Osteotomy Correction of TLKD due to AS by a monosegmental intravertebral closing wedge osteotomy of the lumbar spine was first described by Scudese in 1963 (22) and later by Ziwjan in 1982 (28) and by Thomasen in 1985 (45). This technique encompasses the resection of the posterior elements of one vertebra, including the lamina, articu- lar processes, and pedicles, in combination with the posterior wedge of the vertebral body. Correction is then achieved by passive extension of the lumbar spine, thus closing the posterior osteotomy with an anterior hinge (Fig. 5). A variety of methods of internal fixation such as wiring, metal plates, or transpedicular fixation have been used to ensure immediate stability and rapid consolidation of the osteotomy site (13,17,45,46). The above mentioned three basic surgical techniques are in use to treat TLKD caused by AS (13,27,35,41,47). Currently, authors prefer polysegmental lumbar
210 de Gast Figure 6 Model representation of OWO in a spine. Note the resection of the adjacent articu- lar processes of the vertebra. Considerable elongation of the anterior column occurs after opening the osteotomy. Note that this model does not show a bamboo spine as is the case in ankylosing spondylitis. Abbreviation: OWO, opening wedge osteotomy. posterior wedge osteotomies or a monosegmental or closing wedge posterior osteot- omy above anterior opening wedge osteotomy because of the high complication and mortality rate associated with the latter (2,9,13,16,17,22,35). Nevertheless, the association of open wedge osteotomy (OWO) with a high vascular and neurological complication rate is challenged by several others (6,11,27,29,47). In an attempt to offer the readers of this book a rationale for decision making on the surgical technique that yields the best technical results for the correction of TLKD associated with AS, a structured review of the literature will be presented in this chapter. For the purpose of clarity and uniformity in this chapter, the operative tech- nique of an anterior opening wedge osteotomy according to Smith-Petersen is referred to as OWO (Fig. 3). The technique of polysegmental lumbar posterior wedge osteo- tomies is referred to as polysegmental wedge osteotomies (PWO) (Fig. 4), and the monosegmental posterior closing wedge osteotomy is referred to as closing-wedge osteotomy (CWO) (Fig. 5).
Lumbar Osteotomy in Ankylosing Spondylitis 211 LITERATURE REVIEW A comprehensive search of all journal articles (referred to as reports) was performed. All reports written in English, French, and German, published between 1966 and 2003 and referenced on Medline, concerning lumbar osteotomies for the correction of TLKD because of AS, were included in this systematic review. The reference lists of all reports were also scanned in order to find other reports. From different reports with an overlap in the patient groups (that is, same patients described in both reports) only the report with the most detailed data was used. From each report, only the data of patients with TLKD attributable to AS treated by a surgical cor- rection of the lumbar spine were analyzed. Reports with at least 10 patients and sufficient clinical information were analyzed for demographic data. After a prelimi- nary review of all reports, a list of six data categories was developed, considered by the author as the minimum requirements for meaningful data interpretation. These categories are: (i) at least four patients treated by the same method, (ii) age and sex of patients, (iii) a comprehensible description of the surgical procedure, (iv) radio- graphic assessment of the correction in degrees, (v) complications, and (vi) subjective (patient-reported) outcomes. Only reports analyzable on all six data categories were included for further analysis. The reports were further divided in three groups according to the surgical techniques used (i.e., OWO, PWO, and CWO). From the reports, the degree of postoperative correction, degree of correction at follow-up, loss of correction, superficial infection, deep infection, re-operation, pseudarthrosis, neuro- praxia, retrograde ejaculation, paralysis, and implant failure were recorded and referred to as the technical outcome data. In order to be able to make a comparison of the technical outcome data of the three surgical techniques, the results were graded good, fair, and poor according to Table 3. RESULTS Search of the Literature An extensive search of the literature revealed 61 citations. Of these, 43 reports could be included for further analysis (Table 1). The reasons for exclusion of 18 reports were overlap of patient groups (41–44,48–52) and absence of clinical results (6,8,53–59). Halm et al. (40,41) reported functional outcome analysis using a subjec- tive score. The technical outcome data of these patients are described in more detail in a referred textbook (60). Another author reports on a prospective study with emphasis on clinical outcome data (66). In another report, the results of two surgical methods were presented (35). Because of insufficient clinical data in most of the reports, statistical meta-analysis of the technical outcomes of the three surgical tech- niques was not feasible, let alone of the clinical outcome data. Patient Series and Treatment Groups The 43 reports describe 979 patients treated by lumbar osteotomy for TLKD result- ing from AS; the data are presented in Table 1. In 451 patients (46%; 29 studies) an OWO was performed. A PWO, reported in five studies, was performed in 249 patients (25%). In ten studies, 297 patients (30%) were treated by CWO. Sixteen reports, including 712 (73%) patients, met the criteria for demographic analysis.
212 de Gast Table 1 Data in Series of 979 Patients Treated by Lumbar Wedge Osteotomies for TLKD Because of AS Lumbar wedge osteotomies Open Polysegmental Closing Patients wedge wedge wedge References (n) osteotomies osteotomies osteotomies Mortality Bossers (1) 44 Bradford et al. (29) 88 Briggs et al. (30) 55 Camargo et al. (12) 66 66 1 1 Chapchal (14) 22 78 Chen (2) 16 16 1 34 1 Chen et al. (66) 78 177 2 Dawson (7) 22 21 2 1 Donaldson (31) 66 4 249 4 Emne´us (15) 33 4 3 Goel (3) 11 11 45 Halm et al. (40) 34 1 Ha¨hnel (16) 2 10 12 Hehne et al. (9) 177 1 Herbert (32) 44 2 Herbert (33) 30 30 1 Jaffray et al. (17) 3 1 Junghanns (34) 12 12 6 Kallio (18) 11 11 Kim et al. (67) 45 22 Klems (19) 11 2 2 La Chapelle (20) 11 99 2 Law (26) 120 120 297 34 Lazennec et al. (35) 31 19 Lichtblau and Wilson (36) 5 5 McMaster and 17 17 Coventry (4) McMaster (11) 14 14 McMaster (37) 15 15 Schubert and Polak (21) 22 Scudese and Calabro (22) 1 Simmons (5) 19 19 Smith-Petersen et al. (10) 66 Stuart and Rose (23) 11 Styblo et al. (38) 20 20 Thiranont and 6 Netrawichien (46) Thomasen (45) 11 Thompson and 55 Ingersoll (39) Van Royen and Slot (13) 22 Van Royen et al. (62) 21 Weale et al. (27) 50 50 Weatherley et al. (24) 22 Wilson and Turkell (25) 1 Ziwjan (28) 99 Total 979 451
Lumbar Osteotomy in Ankylosing Spondylitis 213 Table 2 Demographic Data of Series with More Than 10 Patients Female References Patients (n) Mean age (range) Male 7 2 Camargo et al. (12) 66 34 (19–55) 59 4 Chen (2) 16 40 (24–63) 14 1 Chen (78) 78 37 (19–63) 74 3 Goel (3) 11 33 (23–46) 10 Halm et al. (40) 34 41 (24–57) 31 2 Hehne et al. (9) 177 41 (24–65) 15621 5 Kim et al. (67) 45 35 (17–55) 43 6 Lazennec et al. (35) 31 44 (32–61) 26 3 McMaster and Coventry (4) 17 42 (31–49) 11 1 McMaster (11) 14 42 (31–66) 11 3 Styblo et al. (38) 20 41 (19–57) 19 4 Thomasen (45) 11 38 (28–56) 8 5 Van Royen and Slot (13) 22 48 (27–70) 18 6 Van Royen et al. (62) 21 42 (19–61) 16 2 Weale et al. (27) 50 43 (26–57) 44 75 Ziwjan (28) 99 41 (21–56) 97 Combined data 589 40 (17–70) 637 The mean age at the time of operation was 41 years (range 19–73). The male–female ratio was 7.5:1 (Table 2). Eighteen reports, including 646 patients (66%), were ana- lyzed for technical outcome data. Of these, nine reports [including 224 patients (34%)] deal with OWO (3–5,11,12,27,29,35,38), four reports [including 248 patients (38%)] with PWO (2,9,40,62), and six [including 174 patients (26%)] with CWO (13,35,45,46,66,67). Preoperative, Operative, and Postoperative Approaches Few authors describe their preoperative assessment, i.e., measurement of the severity of the TLKD and the degree of correction needed to obtain an appropriate sagittal balance of the spinal column (29,48,61,62,67). Bo¨hm (48) designed a pair of glasses to measure the view angle in relation to the plumb line. Other authors advise to assess the deformity preoperatively by the chin–brow to vertical angle (61,62,67), or by the C7 plumb line on a standing sagittal radiograph of the whole spine (29,67). General anesthesia and fiber optic intubations are the most commonly used techniques during the operative procedure; however, some authors (5,14,15,20) advo- cated local anesthesia. Whereas a prone position of the patient is generally advocated, Adams (6) and Simmons (5) described a surgical technique with the patient in a lat- eral decubitus position. Some authors advised an anterior release prior to or after the osteotomy but before correction in cases of osteoporotic bone, considerable disk cal- cification, and ossification of the anterior longitudinal ligament (5,20,32,33,35,38,62). To prevent neurological complications, gradual plaster correction have been advo- cated in OWO (4,12,15) and CWO (Fig. 7) (16). Neural monitoring (35) and the use of a wake-up test (2,11,29) have been reported sparsely in the earlier reports, but these modalities are used more routinely in present-day procedures (66,67). In early reports no internal fixation was used (1,3,6,10,38,39). Briggs et al. (30) were the first to use a spinal implant, the Wilson spinous process plate. Subsequently, internal wire loop (5,7,22,27,31,34,45,46,49,53), Luque rectangle (5,46), Harrington
214 de Gast Figure 7 Postoperative myelography after OWO shows the course of the dural sac in the spinal canal. Besides a static angular deformation no significant narrowing occurs. Abbreviation: OWO, opening wedge osteotomy. (11,29,38,40,43), and Wisconsin (27,38) posterior compression instrumentation have been used. Recently, pedicle screw fixation has been used to ensure immediate stabil- ity (66,67). Some authors performed lumbar osteotomies both with and without instrumentation (26,27,35,38,45,61). For postoperative treatment, all authors advocated a plaster thoracolumbar sacral orthosis (TLSO) immobilization with one leg included. To prevent a contrac- ture of the immobilized hip joint in patients with inflammatory involvement of the hip joints, changing the side of immobilization of the leg after two months has been advised (13). The total duration of immobilization depended on the surgical tech- nique, the use of internal fixation, the postoperative stability, and the quality of bone. It ranges from two to four months in CWO and 6 weeks to 15 months in OWO and PWO. Mortality Perioperative mortality was reported in 3.5% (34 of 979 patients), mostly (76%; 26 of 34 patients) caused by postoperative pulmonary and intestinal problems, cardiac
Lumbar Osteotomy in Ankylosing Spondylitis 215 failure, and septicemia. There were 26 fatal perioperative complications in OWO, six in PWO, and two in CWO. Thus the incidence of perioperative mortality in OWO was 2.7%, in PWO 0.6%, and in CWO 0.2% (Table 1). The remaining 8 deaths out of 979 reported patients (0.8%) could be attributed to vascular complications. One patient died after a high aortic rupture because of adhesions between the aortic arch and the trachea at the level of a tracheotomy, another one died after erosion of a lumbar artery related to chronic osteomyelitis, and one died of uncontrollable bleeding from small vessels (4,12,27). In one patient, a retroperitoneal hematoma caused compression of the vena cava inferior, which led to a fatal Budd–Chiari syn- drome (40). Fatal aortic rupture has been reported in four patients, all associated with anterior lengthening of the lumbar spine (19,36,24). Of these, three patients were treated by OWO (19,24). In the fourth patient, a fatal rupture of the aorta occurred after manipulation and nonsurgical correction of a severe kyphotic defor- mity in a patient who had been treated previously with radiation therapy for AS (36). Technical Outcome Data Analysis The technical outcome data of 646 patients presented in 18 reports were analyzed. For the overall technical outcome data, see Tables 3–6. For a comparison of the tech- nical outcomes of OWO, PWO, and CWO, see Table 7. In 453 patients, the degree of surgical correction was reported. The average postoperative correction achieved in the lumbar spine ranged from 37 to 40 for the three surgical techniques (Fig. 8). The desired angular correction of the lumbar spine with the use of PWO was not always achieved resulting in a decreased correction (Fig. 9). Unintentionally, the correction appeared to be monosegmental in several cases (2,9,40,62). Halm (40) reported a monosegmental or bisegmental correction in 19 of the 34 patients (56%), and Hehne and Zielke (9) reported a monosegmental correction in 27% of their patients. Insufficient correction or no correction at all has been reported in PWO, especially in patients with osteoporotic bone and calcification of the anterior longitudinal ligament (62). Loss of correction has been reported especially in OWO and PWO, whereas minimal loss of correction occurred in CWO (Tables 4–6). In reports with loss of correction occurring in only one or two patients, this was aver- aged over all reported patients (4,29). Five authors discussed lumbar osteotomy both with and without internal fixation (26,27,35,38,45). They all observed loss of cor- rection related to patients treated without instrumentation. Many complications have been reported. Duramater lacerations, most likely because of adhesion to the ossified ligamentum flavum in AS, were frequently reported in all surgical techniques (2,11–13,15,38,46). Transient nerve root dysfunction was Table 3 Technical Outcome Grading Criteria Good Fusion and consolidation Fair Loss of correction up to 10 Poor No implant failure Pseudarthrosis or loss of correction >10 Neuropraxia, deep infection, or re-operation Implant failure No correction achieved, recurrent deformation Paralysis, vascular complications or fatal complications
Table 4 Comparison of Good vs. Fair and Poor Postoperative Technical Outcomes for the Open Wedge Osteotomy for Reports Fulfilling the Inclusion 216 de Gast Criteria. The Mean Postoperative Correction, Correction at Follow-Up, and the Loss of Correction in Degrees. Range and Median in Parentheses Results Correction References Patients (n) Good Fair Poor Postoperative Follow-up Loss Bradford et al. (29) 8 2 5 1 31 28 3.1 Camargo et al. (12) 66 62 2 Goel (3) 11 9 2 (21–41/29.5) (2–41/29.5) (0–25/0) Lazennec et al. (35) 19 6 12 McMaster (11) 14 13 1 2? ?? 12 2 (22–55/?) 19 0 13 7 0 39 ? ? 28 19 164 50 (25–60/35) 1 41 ? ? (?/?) 0 37.6 32.9 4.7 (26–48/37.5) (20–45/ (0–12/4.5) McMaster and 17 3 39a 32.5) ? Coventry (4) 19 ? Simmons (5) (20–50/36.5) 0 47 ? ? (30–60/?) Styblo et al. (38) 20 0 44.4b 39.9b 4.5b (30–60/42) (19–55/40) (À5–40/0) Weale et al. (27) 50 3 38.7 ? 4.8 (15–64/?) (0–20/?) Total 224 10 Mean 40.3 35.3 3.9 aData reported in 16 patients. bUnpublished data, personal communication.
Lumbar Osteotomy in Ankylosing Spondylitis 217 Table 5 Comparison of Good vs. Fair and Poor Postoperative Outcomes for the Polysegmental Osteotomies for Reports Fulfilling the Inclusion Criteria. The Mean Postoperative Correction, Correction at Follow-Up, and the Loss of Correction in Degrees. Range and Median in Parentheses Results Correction References Patients Poor Postoperative Follow-up Loss (n) Good Fair Chen (2) 16 0 6 0 26.7 25.8 0.9 (10–50/25.6) (10–50/24)a Hehne et al. (9) 177 140 29 Halm et al. (40) 34c 16 13 8 46b 39b 7b Van Royen 21 4 14 (?/?) et al. (62) 4 40.4 36.4 4 (23–67/?) 3 35.9 25.3 10.7 Total 248 170 62 (0–68/36) Mean 15 34.2 6.0 40.3 aRange between brackets. bData reported in 53 patients. cNo data of one patient died after two years. Table 6 Comparison of Good vs. Fair and Poor Postoperative Outcomes for the Closing Wedge Osteotomy for Reports Fulfilling the Inclusion Criteria. The Mean Postoperative Correction, Correction at Follow-Up, and the Loss of Correction in Degrees. Range and Median in Parentheses Results Correction References Patients Poor Postoperative Follow-up Loss (n) Good Fair Cheng et al. (66) 78 76 2 0 34.5a ? ? 45 40 5 (15–60) ? ? Kim et al. (67) 12 6 6 ? ? Lazennec et al. (35) 6 6 0 0 34.0 ? ? 11 10 1 0 47.4 ? ? Thiranont and 22 18 4 32.4 2.7 Netrawichien (46) 174 156 18 (?/?) 0 33.2 ? ? Thomasen (45) (20–45/33.5) Van Royen (13) 0 28.3b Total (12–50/20) Mean 0 35.1c (25–54/34.5) 0 35.4 aAmount of correction in one-level-osteotomies, the author reported a mean correction of 62.2 (39–100) in two-level-osteotomies. bData reported in nine patients. cUnpublished data.
218 de Gast Table 7 Surgical Technique: Comparison of the Neurological Complications and Comparison of Good vs. Fair and Poor Postoperative Outcomes for the Different Surgical Techniques of the Reports Fulfilling the Inclusion Criteria Results Surgical Reports Patients % Neuro- Paralysis Good Fair þ poor technique (n) (n) Praxia Opening 9 224 8.5 3.1 73 27 wedge osteotomy 4 247 11.3 2.0 69 31 6 174 3.6 0.6 194 18 Polysegmental osteotomies Closing wedge osteotomy reported equally in all surgical techniques; however, permanent neurological compli- cations have been reported only in OWO (3.1%; 7 of 224) and PWO (2.0%; 5 of 247) (Fig. 10) (Table 7). Transient and permanent retrograde ejaculation has been reported in seven patients in OWO (27,38). Implant breakage and loosening of the rod–screw Figure 8 Postoperative lateral radiograph of the spine after OWO shows a correction of the TLKD by 43. Abbreviations: OWO, opening wedge osteotomy; TLKD, throcolumbar kyphotic deformity.
Lumbar Osteotomy in Ankylosing Spondylitis 219 Figure 9 (A) Preoperative lateral radiograph of the lumbar spine from a patient with AS. (B) Postoperative lateral radiograph after PWO with USIS-instrumentation shows a correc- tion of 36. (C) After 82 months there is a loss of correction of 33. Note the rod breakage at the highest two levels and failure at the junction of pedicle screw and the rod in the lowest level. Abbreviation: PWO, polysegmental wedge osteotomies.
220 de Gast Figure 10 (A) Preoperative lateral radiograph of the lumbar spine from a patient with a typi- cal Andersson lesion in AS. (B) Postoperative situation after OWO with unintentional retro- listhesis at the level L2–L3. In such circumstances significant narrowing of the spinal canal and the intervertebral foramina may occur. It is to be noted, however, that since the spine is a rigid beam in AS, the neurological consequences of such a narrowing usually prove better than expected. Abbreviations: AS, ankylosing spondylitis; OWO, opening wedge osteotomy. connection has been reported in OWO (3.6%; 8 of 224 patients), PWO (6.5%; 16 of 248 patients) and CWO (1.7%; 3 of 174 patients). Screw breakout of the pedicle during correction in PWO has been reported in patients with osteoporotic bone (62). Re- operations have been reported in seven patients (3.1%) in OWO, 24 patients (9.7%) in PWO, and four patients (2.3%) in CWO. The indication for re-operation was neurological injury, implant failure, nonunion, deep infection, and progressive loss of correction. Deep and superficial infections reported in some reports were as high as 43% (3,4,13,27,35,62). DISCUSSION Three operative techniques have been described to correct TLKD because of AS at the level of the lumbar spine. Which technique can be recommended? Evidence based medicine requires the choice of a surgical technique that provides the best risk to benefit ratio. Therefore, a reliable comparison of outcomes of the three techniques is necessary. However, such a comparison has not yet been reported.
Lumbar Osteotomy in Ankylosing Spondylitis 221 The most important result to emerge from the above review is that it cannot be concluded that one surgical technique is preferable over the other. This conclusion is based on the fact that there were no appreciable differences in mean postoperative correction and complication rates among the three surgical techniques. The present analysis showed that the average postoperative correction achieved in CWO was 3.8 less than in OWO or PWO; however, meaningful interpretation of this difference is not feasible because of the great range of the amount of correction presented. Another reason was insufficiently reported correction at final follow-up in 9 out of the 18 analyzed reports. It should be noted also that in the last decade there are no more reports on OWO, and surgeons focused their attention on CWO. Complications Three types of complications were associated with lumbar osteotomy for the correction of TLKD in AS: (i) loss of correction, (ii) vascular complications, and (iii) neurological complications. Firstly, AS related osteoporosis increases the chance of loss of correction or insufficient correction by implant loosening, implant failure, and pull-out of the laminar hooks and screw breakout of the pedicle (27,29,38,62). These complications have been reported in OWO and PWO especially (Fig. 9) (3,29,33,34,50,62). Theoretically, this may be explained by a technique related lack of primary anterior stability. In case of insufficient correction, the center of gravity of the thorax will remain too far anterior of the spine. As a result, the posterior fusion zone and implants are placed under considerable tension. This increases the risk of implant failure, delayed union or nonunion, and inevitable loss of spinal correction. Secondly, the risk of rupture of the aorta or its branches associated with the anterior lengthening of the lumbar spine in OWO is mentioned in many reports (1,6,9,13,17). Although this risk showed to be small (0.9%; 4 of 450 patients), it cannot be ignored (19,24,36). Vascular injury has been reported if the opening wedge was performed at the level L1–L2 and L2–L3. However, no vascular injury has been reported in associa- tion with procedures below level L3. Thirdly, lumbar osteotomy inevitably carries the risk of neurological complications. Displacement of a vertebral body causing a neu- rological deficit has been referred as a potential risk in lumbar osteotomy (6,26,30,45,49). This has been reported in six patients treated by OWO (2.7%) and in one patient (0.6%) treated by CWO (35,45,53). In these patients, no or insufficient internal fixation was mentioned as the cause of vertebral displacement. Do the results of this study imply that there is no preference at all for one of the surgical techniques? In my opinion the answer to this question is no. Although this review showed no differences between the corrections achieved by the three surgical techniques, the technical outcome data showed that with the use of CWO there is a tendency toward less serious complications. Permanent neurological complications were not reported in CWO. In addition, it should be noted that in the past years sev- eral authors have reported on CWO, not only for AS but also for angular kyphotic deformities (69,70). Such is the case after trauma, congenital deformity, infection, or spinal tumors. The technique described in these reports is a method transpedicular to CWO that has been technically refined and it avoids the use of sudden forces in correcting the spine. It is rather a closing osteoclasis than an opening wedge. Furthermore, loss of correction in CWO was minimal, most probably because of the two cancellous surfaces of the vertebral osteotomy ensuring a rapid consoli- dation after closure. However, the maximum correction achieved with this technique
222 de Gast is restricted by the anatomical limitations of one vertebral body. This showed to be about 35 (15–54) (Fig. 8). Interestingly, some authors report a correction as high as 75 in CWO (35). The only way to explain such a correction by CWO is by fracturing of the anterior hinge of the osteotomy, thus transforming it into OWO. In these instances, additional benefit may be obtained from pedicle screw fixation, since this will lock the corrected position like a tension band (17). Another important result of this study is that the indications for operative treatment were generally poorly defined. Preoperative clinical or radiographic assess- ment of the kyphotic deformity was mentioned in few (5 of 41) reports, and one referred textbook (13,29,38,48,61,62). This is not surprising, as there are no standard- ized parameters for the preoperative and postoperative evaluation of the severity of TLKD due to AS. Different authors suggest different parameters. Assessment of the chin–brow to vertical angle is easy to use; however, its reproducibility and reliability are not known (61,62). Another method is the assessment of TLKD on a standing lateral radiograph of the whole spine (29). On these radiographs, measurements of the horizontal distance from S1 to the sagittal vertical axis or the C7 plumb line are suggested. These measurements, however, are found to differ depending on small changes of the angles of the hip, knee, and ankle joints and therefore are not accurate (63). Furthermore, the exact position of landmarks C7 and S1, and the position of the long cassette film to the horizon are also not known. One recent report presented patients treated by OWO and CWO (35). How- ever, the authors did not compare the results of these two techniques. It can be ques- tioned why there are no studies available comparing different techniques of lumbar osteotomy in AS. The explanation is twofold. Firstly, the number of patients treated by lumbar osteotomy for TLKD due to AS is low and decreasing, most probably because of successful conservative treatment. Our study showed that reports on lum- bar osteotomy are sparse indeed, and that only few authors have experience with a larger number of patients. Secondly, there are no standardized methods for assessing the sagittal deformity of the spine, and accurate preoperative planning including the degree of correction required and the level to operate on (for further details on defor- mity planning in AS see chap. 10). As a result, investigators simply lack adequate data to perform a reliable comparative study. Functional outcome analysis and measuring quality of life is important in sur- gery for TLKD because of AS. Only two authors reported functional and clinical out- come data in spinal osteotomy (41,67). Halm (40,41) used a questionnaire to study retrospectively patients treated in the 1970s and 1980s. Kim (67) prospectively studied 45 patients treated with a CWO, offering the most detailed clinical outcome study so far. All other reports focus on operative technique, degree of correction, and complica- tion rate. Ideally, a study should evaluate the outcome of the operative procedure on the effect it produces on the patient’s quality of life. However, workable methods to assess quality of life in patients with AS have only been developed recently (64,65,67). In line with the technical developments in spinal surgery and the present- day relative constancy of the spinal correction achieved, it is to be expected that future studies will put more emphasis on clinical outcome than on technical outcome (67). CONCLUSIONS The structured review of the literature concerning three methods of lumbar osteotomy for correction of TLKD attributable to AS showed that the number of reliable reports
Lumbar Osteotomy in Ankylosing Spondylitis 223 is limited and that they provide scant information on clinical data. Statistical analysis of the technical outcome data from these surgical methods was therefore not possible. Although the available data from the current literature suggest that CWO causes less serious complications and has better results, these data are not suitable yet for decision-making with regard to which surgical treatment is preferable. Furthermore, there is a need for a generally accepted clinical score that encompasses accurate measurements needed for preoperative and postoperative assessment of the spinal deformity in these patients. Such scores are under development at the present time. REFERENCES 1. Bossers GT. Columnotomy in severe Bechterew kyphosis. Acta Orthop Belg 1972; 38: 47–54. 2. Chen PQ. Correction of kyphotic deformity in ankylosing spondylitis using multiple spinal osteotomy and Zielke’s VDS instruments. J Formos Med Assoc 1988; 87:692–698. 3. Goel MK. Vertebral osteotomy for correction of fixed flexion deformity of the spine. J Bone Joint Surg 1968; 50-A:287–294. 4. McMaster MJ, Coventry MB. Spinal osteotomy in ankylosing spondylitis: technique, complications, and long-term results. Mayo Clin Proc 1973; 48:476–487. 5. Simmons EH. Kyphotic deformity of the spine in ankylosing spondylitis. Clin Orthop 1977; 128:65–77. 6. Adams JC. Technique, dangers and safeguards in osteotomy of the spine. J Bone Joint Surg 1952; 34-B:226–232. 7. Dawson CW. Posterior elementectomy in ankylosing arthritis of the spine. Clin Orthop 1957; 10:274–281. 8. Gerscovich EO, Greenspan A, Montesano PX. Treatment of kyphotic deformity in ankylosing spondylitis. Orthopedics 1994; 17:335–342. 9. Hehne HJ, Zielke K, Bo¨ hm H. Polysegmental lumbar osteotomies and transpedicular fixation for correction of long-curved kyphotic deformities in ankylosing spondylitis. Report on 177 cases. Clin Orthop 1990; 258:49–55. 10. Smith-Petersen MN, Larson CB, Aufranc OE. Osteotomy of the spine for correction of flexion deformity in rheumatoid arthritis. J Bone Joint Surg 1945; 27:1–11. 11. McMaster MJ. A technique for lumbar spinal osteotomy in ankylosing spondylitis. J Bone Joint Surg 1985; 67-B:204–210. 12. Camargo FP, Cordeiro EN, Napoli MM. Corrective osteotomy of the spine in ankyl- osing spondylitis. Experience with 66 cases. Clin Orthop 1986; 208:157–167. 13. Van Royen BJ, Slot GH. Closing-wedge posterior osteotomy for ankylosing spondylitis. Partial corporectomy and transpedicular fixation in 22 cases. J Bone Joint Surg 1995; 77-B: 117–121. 14. Chapchal G. Operative treatment of severe kyphosis as the result of Bechterew’s disease. Arch Chir Neerl 1949; 1:57–63. 15. Emne´us H. Wedge osteotomy of spine in ankylosing spondylitis. Acta Orthop Scand 1968; 39:321–326. 16. Ha¨hnel H. Erste Erfahrungen mit operativen Kyphosekorrekturen bei M. Bechterew und M. Scheuermann. Beitr Orthop Traumatol 1988; 35:153–160. 17. Jaffray D, Becker V, Eisenstein S. Closing wedge osteotomy with transpedicular fixation in ankylosing spondylitis. Clin Orthop 1992; 279:122–126. 18. Kallio KE. Osteotomy of the spine in ankylosing spondylitis. Ann Chir Gynaec Fenn 1963; 52:615–619. 19. Klems VH, Friedebold G. Ruptur der Aorta abdominalis nach Aufrichtungs-operation bei Spondylitis Ankylopoetica. Z Orthop 1971; 108:554–563.
224 de Gast 20. La Chapelle EH. Osteotomy of the lumbar spine for correction of kyphosis in a case of ankylosing spondylarthritis. J Bone Joint Surg 1946; 28:851–858. 21. Schubert T, Polak K. Ergebnisse der operativen Behandlung von Patienten mit Spondy- larthritis ankylopoetica. Beitr Orthop Traumatol 1988; 5:290–295. 22. Scudese VA, Calabro JJ. Vertebral wedge osteotomy. Correction of rheumatoid (anky- losing) spondylitis. J Am Med Assoc 1963; 186:627–631. 23. Stuart FW, Rose GK. Ankylosing spondylitis treated by osteotomy of the spine. Br Med J 1950; 1:165–166. 24. Weatherley C, Jaffray D, Terry A. Vascular complications associated with osteotomy in ankylosing spondylitis: a report of two cases. Spine 1988; 13:43–46. 25. Wilson MJ, Turkell JH. Multiple spinal wedge osteotomy. Its use in a case of Marie Stru¨ mpell spondylitis. Am J Surg 1949; 77:777–782. 26. Law WA. Osteotomy of the spine. Clin Orthop 1969; 66:70–76. 27. Weale AE, Marsh CH, Yeoman PM. Secure fixation of lumbar osteotomy. Surgical experience with 50 patients. Clin Orthop 1995; 321:216–222. 28. Ziwjan JL. Die behandlung der Flexionsdeformita¨ten der Wirbelsa¨ule bei der Bechter- ewschen Erkrankung. Beitr Orthop Traumatol 1982; 29:195–199. 29. Bradford DS, Schumacher WL, Lonstein JE, Winter RB. Ankylosing spondylitis: experi- ence in surgical management of 21 patients. Spine 1987; 12:238–243; Erratum: 590–592. 30. Briggs H, Keats S, Schlesinger PT. Wedge osteotomy of the spine with bilateral, interver- tebral foraminotomy: correction of flexion deformity in five cases of ankylosing arthritis of the spine. J Bone Joint Surg 1947; 29:1075–1082. 31. Donaldson JR. Osteotomy of the spine for kyphus due to Marie-Stru¨ mpell’s arthritis. Indian J Surg 1959; 21:400–402. 32. Herbert JJ. Vertebral osteotomy, technique, indications and results. J Bone Joint Surg 1948; 30-A:680–689. 33. Herbert JJ. Vertebral osteotomy for kyphosis, especially in Marie-Stru¨ mpell Arthritis. J Bone Joint Surg 1959; 41-A:291–302. 34. Junghanns H. Operative rehabilitation bei spondylitis ankylopoetica. Therapiewoche 1971; 24:1835–1838. 35. Lazennec JY, Saillant G, Saidi K, et al. Surgery of deformities in ankylosing spondylitis: our experience of lumbar osteotomies in 31 patients. Eur Spine J 1997; 6:222–232. 36. Lichtblau PO, Wilson PD. Possible mechanism of aorta rupture in orthopaedic correc- tion of rheumatoid spondylitis. J Bone Joint Surg 1956; 38-A:123–127. 37. McMaster PE. Osteotomy of the spine for fixed flexion deformity. J Bone Joint Surg 1962; 44A:1207–1216. 38. Styblo K, Bossers GT, Slot GH. Osteotomy for kyphosis in ankylosing spondylitis. Acta Orthop Scand 1985; 56:294–297. 39. Thompson WAL, Ingersoll RE. Osteotomy for correction of deformity in Marie- Stru¨ mpell arthritis. Surg Gynecol Obstet 1950; 90:552–556. 40. Halm H, Metz-Stevenhagen P, Schmidtt A, Zielke K. Operatieve Behandlung kypho- tischer Wirbelsa¨ulendeformita¨ten bei der Spondylitis ankylosans mit dem Harrington- Kompressions system: Langzeitergebnisse auf der Basis der MOPO-Skalen im Rahmen einer retrospektiven Fragenbogenerhebung. Z Orthop 1995; 133:141–147. 41. Halm H, Metz-Stevenhagen P, Zielke K. Results of surgical correction of kyphotic defor- mities of the spine in ankylosing spondylitis on the basis of the modified arthritis impact measurement scales. Spine 1995; 20:1612–1619. 42. Hehne HJ, Becker HJ, Zielke K. Die Spondylodiszitis bei kyphotischer Deformita¨t der Spondylitis ankylosans und ihre Ausheilung durch dorsale Korrekturosteotomien. Bericht u¨ ber 33 Patienten. Z Orthop 1990; 128:494–502. 43. Pu¨ schel J, Zielke K. Korrekturoperation bei Bechterew-Kyphose. Indikation, Technik, Ergebnisse. Z Orthop 1982; 120:338–342.
Lumbar Osteotomy in Ankylosing Spondylitis 225 44. Zielke K, Rodegerds U. Operative Behandlung der fixierten Kyphose bei ‘‘Spondylitis ankylosans’’. Indikation, Komplikationen und Ergebnisse. Vorla¨ufiger Bericht u¨ ber 78 Fa¨lle. Z Orthop 1985; 123:679–682. 45. Thomasen E. Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin Orthop 1985; 194:142–152. 46. Thiranont N, Netrawichien P. Transpedicular decancellation closed wedge vertebral osteotomy for treatment of fixed flexion deformity of spine in ankylosing spondylitis. Spine 1993; 18:2517–2522. 47. Simmons EH. Relation of vascular complication to the level of lumbar extension osteot- omy in ankylosing spondylitis. Presented at the 61st Annual Meeting of the American Academy of Orthopaedic Surgeons, New Orleans, USA, Feb 25, 1994. 48. Bo¨ hm H, Hehne HJ, Zielke K. Die Korrektur der Bechterew Kyphose. Orthopa¨de 1989; 18:142–154. 49. Law WA. Lumbar spine osteotomy. J Bone Joint Surg Br 1959; 41-B:270–278. 50. Law WA. Osteotomy of the spine. J Bone Joint Surg Am 1962; 44-A:1199–1206. 51. Pu¨ schel J. Korrekturosteotomien beim M. Bechterew-Kyphose. Technik, Ergebnisse. Z Orthop 1981; 119:823–824. 52. Roy-Camille R, Henry P, Saillant G, Doursounian L. Chirurgie des grandes cyphoses vertebrales de la spondylarthrite ankylosante. Rev Rhum Mal Osteoartic 1987; 54: 261–267. 53. Chapchal G. Columnotomy in severe Bechterew kyphosis. Acta Orthop Belg 1972; 38: 55–58. 54. Dahmen G. Operative Behandlung der Bechterewschen Erkrankung. Med Monatsschr 1972; 26:194–201. 55. Junghanns H. Aufrichtungsoperation bei spondylitis ankylopoetica (Bechterew). Dtsch Med Wochenschr 1968; 93:1592–1594. 56. Junghanns H. Operative Behandlung schwerer Kyphosen und Hu¨ ftarthrosen bei ankylo- sierender Spondylitis. Verh Dtsch Ges Rheumatol 1969; 1:171–178. 57. Law WA. Surgical treatment of the rheumatic diseases. J Bone Joint Surg Br 1952; 34-B: 215–225. 58. Law WA. President’s address. Ankylosing spondylitis and spinal osteotomy. Proceedings of the Royal Society of Medicine 1976; 69:715–720. 59. Morscher E, Mu¨ ller W. Operative Korrektur fixierter Kyphosen. Orthopa¨de 1973; 2: 193–200. 60. Hehne HJ, Zielke K. Die Kyphotische Deformita¨t bei Spondylitis ankylosans. Klinik, Radiologie und Therapie. In: Schulitz KP, ed. Die Wirbelsa¨ule in Forschung und Praxis Vol. 112. Stuttgart: Hippocrates Verlag, 1990:32–69. 61. Simmons EH. Ankylosing spondylitis: surgical considerations. In: Rothman RH, Simeone FA, eds. The Spine, Vol. 2. 3rd ed. Philadelphia: WB Saunders, 1992:1447–1511. 62. Van Royen BJ, De Kleuver M, Slot GH. Polysegmental lumbar posterior wedge osteo- tomies for correction of kyphosis in ankylosing spondylitis. Eur Spine J 1998; 7:104–110. 63. Van Royen BJ, Toussaint HM, Kingma I, et al. Accuracy of the sagittal vertical axis in a standing lateral radiograph as a measurement of balance in spinal deformities. Eur Spine J 1998; 7:408–412. 64. Abbott CA, Helliwell PS, Chamberlain MA. Functional assessment in ankylosing spondylitis: evaluation of a new self-administered questionnaire and correlation with antropometric variables. Br J Rheumatol 1994; 33:1060–1066. 65. Kennedy LG, Jenkinson TR, Mallorie PA, Whitelock HC, Garrett SL, Calin A. Ankylosing spondylitis: the correlation between a new metrology score and radiology. Br J Rheumatol 1995; 34:767–770. 66. Cheng I-H, Chien J-T, Yu T-C. Transpedicular wedge osteotomy for correction of thoracolumbar kyphosis in ankylosing spondylitis. Spine 2001; 26:354–360.
226 de Gast 67. Kim K-T, Suk K-S, Cho Y-J, Hong G-P, Park B-J. Clinical outcome results of pedicle subtraction osteotomy in ankylosing spondylitis with kyphotic deformity. Spine 2002; 27:612–618. 68. Suk K-S, Kim K-T, Lee S-H, Kim J-M. Significance of chin–brow vertical angle in correction of kyphotic deformity of ankylosing spondylitis patients. Spine 2003; 28: 2001–2005. 69. Kawahara N, Tomita K, Baba H, Kobayashi T, Fujita T, Murakami H. Closing–opening wedge osteotomy to correct angular kyphotic deformity by a single posterior approach. Spine 2001; 4:391–402. 70. Bridwell KH, Lewis SJ, Edwards C, et al. Complications and outcomes of pedicle subtraction osteotomies for fixed sagittal imbalance. Spine 2003; 18:2093–2101.
16 Image-Based Planning and Computer Assisted Surgery in Ankylosing Spondylitis Michael Ruf, Viktor Moser, and Ju¨ rgen Harms Department of Spinal Surgery, Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany INTRODUCTION Ankylosing spondylitis is a chronic inflammatory disease leading to increasing stiffness and kyphotic deformity of the spine. Conservative treatment, especially intensive physiotherapy, is necessary to keep patients mobile and to prevent defor- mity as long as possible. Despite these efforts, in many patients ankylosis progresses from the lumbar and thoracic spine to the cervical spine. These patients end up in a fixed kyphosis of the thoracolumbar spine without the possibility to compensate in the cervical region. The horizontal gaze becomes increasingly difficult for the patient. To obtain an upright position, the patient tilts his pelvis back with retroversion of the sacrum. This compensatory rotation of the pelvis leads to a continuous hyperextension of the hip joints, which may cause additional pain. Besides, this hyperextension is often limited by an accompanying coxarthritis in the ankylosing spondylitis patient. The patient then has to bend his knees in an attempt to assume the upright position. Surgical therapy has to facilitate the patient’s life with his stiff spine. The aims of surgical therapy, therefore, are: To restore the sagittal profile, To normalize the gravity line, To normalize the position of the sacrum and pelvis, and To normalize the position of the head. Normalization of the pelvic tilt reduces the stress in the hip joints due to hyper- extension. The normalization of the gravity line reduces the muscle strain that is necessary to balance the trunk in an upright standing position. Normalization of the head position allows for a horizontal gaze without painful hyperextension of the possibly still flexible cervical spine. 227
228 Ruf et al. To meet these requirements and to achieve predictable surgical results with optimal correction of the malformation, precise preoperative planning and exact surgical realization is required. Since the spine in an advanced ankylosing spondylitis is a rigid piece of bone, the effect of a defined correction osteotomy on the overall sagittal profile is predictable by simple mathematical calculations. The angle and the level of this calculated correction osteotomy is then realized during surgery. The ideal device to transfer the preoperative planning to surgery is an appropriate navigation system. The data of the calculated osteotomy are entered into the navigation system, and the system allows precise corrective procedures along premarked lines with image guided tools. A technique of preoperative planning and surgical realization, and results thereof in patients afflicted by ankylosing spondylitis has been described below (1). Figure 1 Lateral radiograph of a 40-year-old patient with ankylosing spondylitis in standing position.
Image-Based Planning and Computer Assisted Surgery 229 PREOPERATIVE PLANNING Preliminary Remarks Planning of the correction should consider the following aspects: Effect on the position of the head (line of vision), Effect on the gravity line, Effect on the position of the sacrum and the pelvis, and Technical requirements. Two variables have to be determined: 1. The level of the osteotomy and 2. The angle of correction. When we select the level of the osteotomy we have to consider its influence on the overall sagittal profile as well as its technical requirements. Correction with a predetermined angle via a fulcrum close to the sacrum has more impact on the grav- ity line than correction with the same angle via a more cranial pivot. The impact on the inclination of the head, which depends only on the angle of correction, is affected similarly. To achieve a maximum effect on the gravity line, the osteotomy should be performed as caudally as possible. Furthermore, an osteotomy in the lum- bar spine is technically less demanding and associated with minor neurological risk Figure 2 The pelvis is rotated backwards to allow an upright standing position: sacral slope 29, sacrofemoral tilt 31.
230 Ruf et al. in comparison with osteotomy in the thoracic spine. On the other hand, a certain distance of the osteotomy from the sacrum is required for sufficient distal fixation in the usually osteoporotic bone. Accordingly, L3 is usually the favored osteotomy site. This level has sufficient effect on the gravity line and concurs ideally with the technical requirements. There are, however, a few cases that require an osteotomy in the thoracic or cervical spine, mostly in posttraumatic cases or patients with Anderson lesions. The selection of the correction angle has to consider its influence on the overall sagittal profile, especially gravity line, head inclination, and tilt of the pelvis. We have to normalize the gravity line to enable the patient to stand upright comfortably in a position where muscle activity is minimized. The optimal gravity line in ankylosing spondylitis patients is not yet well defined. In our opinion the plumb line from the center of the vertebral body of C7 should fall behind the center of the femoral heads through the endplate of S1 close to the anterior edge of S1. Equally important is normalization of sacral inclination to avoid continuous hyperextension of the hip Figure 3 The radiograph is rotated (11 clockwise) to achieve a normal sacral slope of 40. The pivot is defined at the level of L3.
Image-Based Planning and Computer Assisted Surgery 231 joints or, what is worse, the bending of knees while standing. The head should obtain a neutral or slightly anteflexed position to allow the patient to observe his feet. Preoperative Planning Anteropostero and lateral radiographs of the entire spine including sacrum and hip joints were obtained in a standing position (Figs. 1 and 2). The first step of the planning procedure is virtual correction of the retroversion of the sacrum, thereby achieving correction of the pelvic tilt. The lateral radiograph of the whole spine is digitized and entered into a computer drawing program. The radiograph is then rotated to a normal sacral slope of 40–45. The level of osteotomy is defined, in most cases at the level L3 (Fig. 3). In a second step, the upper part of the radiograph (above the osteotomy level) is rotated backwards. The fulcrum of this rotation is situated near the superior– anterior cortex of the predetermined vertebra at the osteotomy level. This fulcrum Figure 4 The upper part of the spine (above L3) is rotated backwards, until the gravity line is normalized: 28 anticlockwise. This represents the planned correction angle.
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